New Account Application

ACCOUNT INFORMATION
Company*
Primary Service Area*
Phone*
Fax
Website
Address*
Street Address Address Line 2 City State ZIP Code
Primary Contact*
First Last
Primary Contact Title*
Primary Contact Phone*
Primary Contact Email*
Secondary Contact
First Last
Secondary Contact Title
Secondary Contact Phone
Secondary Contact Email
Preferred Purchase Method*
BILL TO
where to send invoices
Billing Contact
First Last
Billing Contact Title
Billing Contact Phone
Billing Contact Fax
Billing Email
Primary Ship To
if different
Company
Shipping Contact
First Last
Shipping Address
Street Address Address Line 2 City State ZIP Code
Shipping Phone
Shipment Tracking Email
Credit Card Information
Name as it Appears on Card
Billing Zip Code
Card Number
CVC
Expiration Date
Terms And Conditions
Payment due in full net 30 days from date of invoice. All invoices will be emailed to the Billing Contact unless otherwise directed. Advanced Integrated Motion reserve the right to charge the credit card on file for past due balances.
Consent*
I accept the TERMS AND CONDITIONS
I hereby accept the above TERMS AND CONDITIONS and state that all information contained herein is complete and accurate.
Name*
First Last
Date*
MM slash DD slash YYYY
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ACCOUNT INFORMATION