New Client Form – Plan First Technologies, Inc

Company Details

Business Name: *

*That you would accept payments or pay bills as.

Type of Business: *

In Business Since: *

Business Primary Phone Number: *

Business Primary Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Legal Form Under Which Business Operates: *

Corporation
Partnership
Proprietorship

Tax I.D. Number *

Tax Exempt: *

Yes
No

Tax Exempt Form Upload: *

Click or drag a file to this area to upload.

Is the business a Division or Subsidiary: *

Yes
No

Name of Parent Company: *

Parent Company in Business Since: *

Business & Technical

Business Owner Name: *

First

Last

Business Owner Title: *

Business Owner Email: *

Is the owner the technical contact: *

Yes, contact them with technical questions.
No, there is an additional contact that handles technical questions.

Question Types: What Operating System does your server run? Do you have a Firewall, how is it configured? Etc.

Technical Contact: *

First

Last

Technical Contact Title: *

Technical Contact Email: *

Day-to-day Business Transactions

Business Transactions Contact: *

First

Last

This contact is approved to make billable decisions on behalf of the business.

Business Transactions Contact Title: *

The address for this client is the same as the primary contact

Yes
No

Business Transactions Contact Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Business Transactions Preferred Contact Method: *

Email
Phone

Business Transactions Contact Phone: *

Business Transactions Contact Email: *

Accounts Payable

Accounts Payable Contact: *

First

Last

This contact is approved to make financial and clerical support decisions on behalf of the business.

Accounts Payable Contact Title: *

The address for this client is the same as the primary contact

Yes
No

Accounts Payable Contact Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Accounts Payable Preferred Contact Method: *

Email
Phone

Accounts Payable Contact Phone: *

Accounts Payable Contact Email: *

Credit Terms

Would you like Credit terms: *

Yes
No

Should you select "No" then by default your account will be set up as "Due on Receipt". By filling out the "Credit Terms" section we may be able to extend you credit terms of Net 30 giving you time to pay your invoices rather than have them due immediately.

Number of Bank References:

Selected Value: 1

Select how many bank references you have. (1-2)

Primary Bank Reference

Bank Name (Primary): *

Bank Account Type (Primary): *

Bank Notes (Primary):

Secondary Bank Reference

Bank Name (Secondary): *

Bank Account Type (Secondary): *

Bank Notes (Secondary):

Number of Trade References:

Selected Value: 1

Primary Trade Reference

Trade Reference Company Name (Primary): *

Trade Reference Contact Name (Primary): *

First

Last

Trade Reference Address (Primary): *

Address Line 1

Address Line 2

City

State

Zip Code

Trade Reference Phone (Primary): *

Trade Reference Account Open Since (Primary): *

Trade Reference Credit Limit (Primary): *

Trade Reference Current Balance (Primary): *

Secondary Trade Reference

Trade Reference Company Name (Secondary): *

Trade Reference Contact Name (Secondary): *

First

Last

Trade Reference Address (Secondary): *

Address Line 1

Address Line 2

City

State

Zip Code

Trade Reference Phone (Secondary): *

Trade Reference Account Open Since (Secondary): *

Trade Reference Credit Limit (Secondary): *

Trade Reference Current Balance (Secondary): *

Credit Acknowledgement

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein. Standard terms are Net 30. Consistent late payments could cause loss of terms and account status change to COD. Down payments are often required for equipment purchases. In the event collection proceedings are required for past due balances by signing you agree to be responsible for any and all legal fees. *

I've read the above credit acknowledgement and have filled the form out to my best ability.

Signature *

Clear Signature

Date / Time *