Date: _______________

APPLICATION FOR OPEN ACCOUNT

Please forward to: Advanced Industrial Solutions
3921 Kelly Lane
Ponder, TX 76259
Brandon@tx-ais.com

Company Name: ___________________________________________________

State Tax ID ______________________
Bill To Address: ______________________________________

Federal Tax ID ____________________

City, State Zip: ________________________________________

Years In Business _________________

Phone: _______________________

Fax: _________________

Ship To Address: ______________________________________

City, State Zip: ________________________________________
AP Contact: _________________________ Email:_______________________ Phone: ____________________
Purchasing Contact: _____________________ Email: _______________________Phone: ____________________
Type of business

Proprietorship

Partnership

Corporation in State _______________

Will your purchases be Taxable?

Yes
Exempt on some items
Please Submit a Tax Exemption form with application
Would you like your invoices:

Mailed

Emailed

Exempt on all items

Faxed

Officers or Partners if different than above:

Name: ________________________________ Title __________________________Phone ____________________
Name: ________________________________ Title __________________________Phone ____________________
Name: ________________________________ Title __________________________Phone ____________________
Bank Reference (name): _________________________________ Bank Contact: ___________________________
Address:_____________________________________________________________________
City: ___________________________ State: __________________ Zip: _________________
Phone: _________________________

Fax: _____________________________

Trade Reference (name): ______________________________________ Account # : ______________________

Address:_____________________________________________________________________
City: ___________________________ State: __________________ Zip: _________________
Phone: _________________________

Fax: _____________________________

Trade Reference (name): ______________________________________ Account # : ______________________

Address:_____________________________________________________________________
City: ___________________________ State: __________________ Zip: _________________
Phone: _________________________

Fax: _____________________________

Trade Reference (name): ______________________________________ Account # : ______________________

Address:_____________________________________________________________________
City: ___________________________ State: __________________ Zip: _________________
Phone: _________________________

Fax: _____________________________

Requested credit amount: $_________________

The above information is submitted for the purpose of opening an account and I certify that the information is true.

Name: _________________________Signature_______________________________ Title ______________