APPLICATION FORM Step 1 of 3 33% Company Name* Federal ID (EIN)* Mailing Address* Street Address Address Line 2 City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are Mailing address and Billing address the same?* Yes No Billing Address Street Address Address Line 2 City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Credit Requested* $1,000 $5,000 $10,000 (monthly purchases must average $500 or more to qualify) COMPANY INFO:Accounts Payable Contact* Phone*Email* Year Established* Legal Entity* Corp. Partnership Proprietorship Purchase Orders Required* Yes No (All invoice copies will be emailed)AZ State Sales Tax Exempt* Yes No (If yes, please provide the following: Arizona Form 5000 or letter from state regarding status as an exempt Qualifying Health Care Organization) PERSONS AUTHORIZED TO CHARGE TO THIS ACCOUNT:Name* Title* Name Title Name Title Name Title It is hereby certified that the statements in this Application for Open Account are true and complete. By the signature below, the purchaser hereby agrees to pay all invoices when same become due and payable pursuant to the terms of the sale. Pixa’s standard terms of sale are payment within 30 days of invoice date. The purchaser agrees to pay all collection costs and attorney’s fees necessary to collect this account if necessary. The undersigned waives notice of acceptance, note of non-payment, protest and notice of protest with respect to the obligations covered herein. The undersigned authorizes creditors and vendors to provide account and experience information toPixa.Date* Name* Title* NameThis field is for validation purposes and should be left unchanged.
