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New Customer Application

Business Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Website URL*

Primary Contacts

Primary Contact Name *

Phone Number*

Email Address*

Title*

Billing Address

Same as business address and primary contact.

Accounts Payable Contact Name*

A/P Email Address*

A/P Phone Number*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Credit Terms

Requested Credit Limit*

$1,000

$5,000

$10,000

$25,000

Requested Payment Terms*

COD

Net 15

Net 30

1%10 Net 30

Trade References

Reference 1 Company Name*

Reference 1 Contact Person

Reference 1 Phone Number

Reference 2 Company Name*

Reference 2 Contact Person

Reference 2 Phone Number

Reference 3 Company Name*

Reference 3 Contact Person

Reference 3 Phone Number

Banking Information

Bank Name*

Banking Contact*

Bank Phone Number*

Account Number*

Additional Information

Types of service needed

Expected Monthly Project Volume

<$1000

$1,000 - $2,500

$2,500 - $5,000

$5,000 - $15,000

$15,000+

Special Requirements

info@moltenmfg.com

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New Customer Application ​

Company Information