Please enable JavaScript in your browser to complete this form.1Company Information2Company Financial Information3Shipping Information4ApprovalCompany Name *Accounts Payable Contact Name *FirstMiddleLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *FaxEmail *Website / URLNextWould you like your invoices emailed?YesNoIf you want your invoices emailed, please specify an email address *EmailConfirm EmailIs there an email address you'd like order confirmations sent?YesNoIf you want an order confirmation emailed, please specify an email address (copy) *EmailConfirm EmailRequested Payment Terms (click to select) *Net 30Credit Card or CIAOtherCredit references are required for Net 30 terms. Payment terms are granted on credit worthiness. Please contact us directly if you would like to discuss non-standard payment arrangements.File UploadCompany Name 1 *Phone 1 (copy) *Email 1 *Company Name 2Phone 2 *Email 2 *Company Name 3Phone 3 *Email 3 *Company Tax Status *Taxable On All OrdersTax Exempt On All Orders*Tax Exempt On Some Orders**Tax Exemption or Resale Certificate RequiredFile UploadCompany Type *End-UserInstaller or General ContractorOEM CustomerOther (please specify)If Other, please SpecifyNextCompany Name (shipping)Shipping Contact Name *FirstMiddleLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeShipping Contact Phone *Email *Would you like shipment tracking information sent to this address? *YesNoNextYour Name *FirstLastBy entering your name and submitting this form, you certify that the information provide is true and correct. You are authorizing AIRSYS Cooling Technologies to verify this information and/or obtain additional information by securing data from a credit agency.Title *Date *Additional Comments or NotesNameSubmit