New Account Application Company Name * Primary Contact Name * First Name Last Name Title * Phone * (###) ### #### Email * Accounts Payable Contact Information Name First Name Last Name Billing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Method of Communication Phone Call Email Text Message Accounts Payable Email Delivery Address (If different than billing address) Address 1 Address 2 City State/Province Zip/Postal Code Country Delivery Hours Our Legal Entity Is Corporation Partnership Proprietorship Other Federal ID # Number of Years in Business Have you ever done business under another name or used a D.B.A.? Yes No If so, what name? Has the above name ever filed a chapter in the United States Bankruptcy court or made an assignment for the benefit of creditors? * Yes No Officer, Partner, or Owner's Information Name First Name Last Name Title Phone (###) ### #### Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Purchasing Are purchase order (PO) numbers required? Yes No Is your purchase from TJP sales tax exempt? Yes No If "Yes", please enter your sales tax exempt # Estimated usage of gallons a month Local Credit References #1 Company Name Email Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country #2 Company Name Email Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country #3 Company Name Email Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Communication I would like to receive text notifications for the following: Completed Propane Deliveries Completed Service Calls Both Name First Name Last Name Mobile Phone Number (###) ### #### By checking "I agree" and submitting this form you are consenting to receive text messages from Twilio autodialer. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying * STOP. I agree TERMS Invoices are net 10 days. Customer agrees to remit payment within 30 days or be subject to COD terms. Any outstanding balance is subject to a finance charge at the highest allowable rate by law. I agree to pay all court costs, attorney fees, and/or collection fees for the unpaid balance. I hereby under the penalty of perjury, certify that I am an active company principle and assume full personal responsibility for the debts incurred by the applying company. I hereby release the above named entities' credit information, and authorize Ted Johnson Propane Co. and its agents to check this company's credit history. By checking this box you are agreeing to the above statement: * I agree By typing my name & title below I agree * Date * MM DD YYYY How did you hear about us? * YouTube Ad Yelp Referral Network Event I saw one of your trucks! Search Engine Thank you!
