Become a New Customer (no credit)

Company Name: *

Billing Address: *

City: *

State: *

Zip Code: *

Phone Number *

Shipping Street Address (If Different Than Billing):

City:

State:

Zip Code:

What is your preferred pick up location? *

Sales Tax Exempt *

Yes, if exempt will need copy of signed sales tax certificate

No

Signed Sales Tax Certificate

Type of Business: *

What best describes your work? *

Industrial

Contractor

Monthly Statement Required *

Yes

No

A/P Contact Name *

Email Address: *

Full Name: *

Job Title: *

Phone Number *

Customer consents to the release of credit reference or credit information at any time by any party listed as a Credit or Bank Reference. Customer agrees to pay Van Meter Inc.’s actual attorneys’ fees in the event delinquent account balances are referred to an attorney for collection. This agreement and any actions between the parties to this agreement shall be governed in Washington County, MN, and the parties agree that this is an appropriate venue as Van Meter Inc. is located in Washington County and this agreement shall be deemed entered into in Washington County, MN. Terms are credit card only; past-due balances bear interest at the rate of 1.5% per month. The undersigned warrants the accuracy of the above information and agrees to the terms set forth above.

E-Signature *

clear

Date (MM-DD-YYYY): *