NEW CLIENT INFORMATION – Clean Water of New York, Inc

Company Name(Required)

Contact Name(Required)

Physical Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Mailing Address

Same as Company Information

Mailing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone(Required)

Fax Number

Email Address(Required)

Purchase order required for service(Required)

Yes

Is your firm and/or services provided exempt from sales tax(Required)

Yes

Signature of person completing this form(Required)

Date(Required)

Print Name(Required)

Title(Required)

Company Information

Company Name

Mailing Address

Contact Name

Telephone

Fax

Email Address

Website

Federal Tax ID

NAICS Code

Billing/Invoice Information

SAME AS COMPANY INFORMATION

Company Name

Physical Address

Mailing Address

Contact Name

Telephone

Fax

Email Address

Purchase order required for service

YES NO

Is your firm and/or services provided exempt from sales tax

YES NO

PERSON COMPLETING THIS FORM:

Signature :

Date :

Print Name & Title :