* - required fields
* Company Name:		* Address:
* City:		* State:
* Zip:		* Telephone:
* Fax:		* Division or subsidiary of:
Bill to Address (if different):
Address:		City:
State:		Zip:
Telephone:		Fax:
Division or subsidiary of:
Company Information
* Type of Business:	CORPORATION   PROPRIETORSHIP   PARTNERSHIP
* Line of Business:		* State Incorporated:
* # of Employees:		* Federal ID Tax No.:
* How long in business:		* Duns Number:
Financial Data
* Estimated business with KahnTact USA, Inc.:		* Net Worth: $
* Line of credit requested:		* Company Annual Sales:
* Accounting Contact:		* Resale certificate no or tax exemption no.:
Corporate Offices / Owner
* Name:		* Title:
* Name:		* Title:
* Name:		* Title:
Bank Reference
* Bank Name:		* Bank Officer:
* Address:		* Account no.:
		* Telephone#
Trade Reference
* Name:		* Contact:
* Address:		* Telephone:
* Fax:
* Name:		* Contact:
* Address:		* Telephone:
* Fax:
* Name:		* Contact:
* Address:		* Telephone:
* Fax:
Credit Terms ALL PAYMENTS MUST BE RECEIVED AT KAHNTACT USA, INC. NO LATER THAN 30 DAYS FROM THE DATE OF THE INVOICE, PAYMENTS RECEIVED AFTER 30 DAYS ARE SUBJECT TO A LATE PAYMENT CHARGE OF 1.5% PER MONTH OR ANY PART OF.
* Date:		* Name:
* Firm:		* Title: