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Please complete and submit this Application for consideration of Net 30 Day Payment Terms for subsequent orders.

*Legal Name of Company
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*Billing Address line 1
Billing Address line 2

*Billing City
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*Billing Zip/Postal Code
*A/P Contact Name

*A/P Contact Email
*Accounts Payable Phone#
Fax#
*Federal Tax ID#
*Bill To Email

Thank you for your interest in Phoenix Distribution & Marketing! Once your Application has been submitted and reviewed, we will contact you with results via email within 2 business days.