NEW CLIENT INFORMATION – Clean Water of New York, Inc

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:

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Date :

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