Company Name *

Date Business Commenced *

Billing Address Line 1 *

Billing Address Line 2

City *

State *

Zip *

Phone *

Fax

Email *

Invoice Email *

Type of Business *

Sole ProprietorshipPartnershipCorporationOther

DUNS # / License

State Resale # *

EIN

Bank Name

Bank Email

Type of Bank Account

SavingsCheckingOther

Bank Address

Note: If you would like to be considered for credit with Durato International, please provide references including email addresses. If no references are given, your account will be CBD Always.

Trade Reference #1

Trade Reference #2

Warehouse / Receiving POC

Receiving Phone

Receiving Hours

Liftgate Needed? *

YesNo

Notify Before Delivery? *

YesNo

Limited Access (No 53' truck)? *

YesNo

On-site Equipment (Check all that apply):

ForkliftLoading DockPallet JackNone

Signature (Type Your Full Name) *