Print this page and fax to us (850)670 1122 or if you have a Purchase order already made out simply fax it to us.

OPEN ACCOUNT APPLICATION FOR GOVERNMENT DEPARTMENTS
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All information contained in this application will remain confidential.

Date:_______________                                                       Department Name:______________________________  

 
Mailing Address:______________________________________________________________

Billing Address: ______________________________________________________________

Telephone:___________________________              Fax:______________________________

Name and telephone # of Senior Person in the Department _________________________

We require a Purchase order (PO) sent to us by Fax for all orders.  
The undersigned certifies that this application has been accurately completed and represents current data.    This application is made with the understanding and agreement that all charges will be due and payable by the 10^th day of the month following charges, unless other terms are stated thereon, and that a monthly service charge of 1.5%  will  be paid on all balances which are past due. 

Name_____________  Signature____________    Title____________