COMPANY INFORMATION
 
 Company Name:    Date: 
 Bill to Name:  
   Corporation Partnership LLC Other:   
 Federal ID:               Dun & Bradstreet No:  
 Accounts Payable Contact:  
    Phone/Fax:        (Ex) 999-999-9999
    Email:  
 Shipping Address:  
 City/State/Zip:  
 Billing Address:  
 City/State/Zip:  
 Purchasing Agent:  
    Phone/Fax:        (Ex) 999-999-9999
    Email:  
 Purchase Order Required? Yes No
 Sales Tax Exempt? Yes No    Exempt No:   
 
 BANK INFORMATION
 
 Bank Name:  
 Bank Officer.:  
 Street:  
 City/State/Zip:  
 Phone/Fax:    
 
 SHIPPING INFORMATION
 
 Do you have a dock? Yes No
 Pallet Jack Required? Yes No
 Receiving Hours:  
 Special Receiving Instructions:  
 
 BUSINESS REFERNCES
 
 Business Name 1:  
    Street:  
    City/State/Zip:  
    Contact Person:  
    Phone/Fax:    
    Email:  
 Business Name 2:  
    Street:  
    City/State/Zip:  
    Contact Person:  
    Phone/Fax:    
    Email:  
 Business Name 3:  
    Street:  
    City/State/Zip:  
    Contact Person:  
    Phone/Fax:    
    Email:  


 Name of Person completing form:   *  (Required)
    Phone/Fax:    
    Your Email:   *  (Required)
    Name of Salerperson at SANECK:   *  (Required)
 
 
 
 
  *Please return to Attn: Tamra Salyer by FAX: (614) 890-0467 or TSalyer@pdisaneck.com.
** All information provided will be held in the strictest of confidence and only used internally.