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Capital Express - Create Customer Account

* Mandatory Fields

Account Name * :
Parent Account * :
Federal Id # :
Address
Street :
City :
State :
Zip :
Suite :
Contact Info
Phone :
Fax :
Toll Free :
Email Address * :
Billing Address :
Online Requests
Online Order Entry :
Yes No
Receive Invoice Online :
Yes No
Special Instruction :
Reference Or P.O. # REQ'D :
Yes No
Expected Activity [each month] :
Years In Business :
Type of Business :
Bank :
Address
Street :
City :
State :
Zip :
No. Of Years :
Owner Office
Address Details :
Address Details :
Trade References
Phone # :
Address :
Phone # :
Address :
Phone # :
Address :
Accounts Payable Contact
Name :
Address :
Phone :
Email Address * :
Type the characters you see in the picture above.
I, hereby grant permission to the references above to release any information necessary to establish this account.

Terms:
  • Payments due upon receipt of invoice.
  • A charge of 1.5% per month is charged on balances over 30 days old.