1Company Information

2Company Financial Information

3Shipping Information

4Approval

Company Name *

Accounts Payable Contact Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Fax

Email *

Website / URL

Would you like your invoices emailed?

If you want your invoices emailed, please specify an email address *

Confirm Email

Is there an email address you'd like order confirmations sent?

If you want an order confirmation emailed, please specify an email address (copy) *

Confirm Email

Requested Payment Terms (click to select) *

Credit 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 Upload

Company Name 1 *

Phone 1 (copy) *

Email 1 *

Company Name 2

Phone 2 *

Email 2 *

Company Name 3

Phone 3 *

Email 3 *

Company Tax Status *

Taxable On All Orders
Tax Exempt On All Orders*
Tax Exempt On Some Orders*

*Tax Exemption or Resale Certificate Required

File Upload

Company Type *

End-User
Installer or General Contractor
OEM Customer
Other (please specify)

If Other, please Specify

Company Name (shipping)

Shipping Contact Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Shipping Contact Phone *

Email *

Would you like shipment tracking information sent to this address? *

Your Name *

First

Last

By 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 Notes