APPLICATION FOR ACCOUNT STATUS WITH MIDWAY MACHINE

Wisconsin sales and use exempion certificate
print out and send with account application

Date: ____________

ACCOUNT NAME: ____________________________________________________________

ADDRESS: _____________________________ CITY: ________________________________

STATE: _________ ZIP: __________ PHONE: _____________________________

FAX: __________________________ CONTACT NAME: ___________________________

SHIPPING ADDRESS (IF DIFFERENT FROM ABOVE): __________________________

CITY/STATE/ZIP: ____________________________________________________________

AUTHORIZED PURCHASER(S): ______________________________________________

CREDIT INFORMATION:

CHECK ONE: CORPORATION______ PARTNERSHIP_____ PROPRIETORSHIP______

ACCOUNT TYPE REQUESTED: OPEN ACCOUNT_____ C.O.D.____ CREDIT CARD______

SALES TAX NUMBER: _____________________________ DATE BUSINESS ESTABLISHED: _____________

COMPANY OFFICERS:

Principal Names SS# Title Home Address Home Phone

Commercial Trade References:

Name Address City/State/ZIP Phone

Bank References:

Name Account Number City/State/ZIP Phone

I hereby authorize the above references to supply Midway Machine with relevant information concerning financial relationship.

X Signed__________________________________________________ Date__________________

X Signed__________________________________________________ Date__________________

Please send the completed form along with your work order & PARTS, OR mail to Midway Machine 9832 HWY 54 E, WIS. RAPIDS WI 54494 OR FAX 1-715-424-2162.

We will require a state resale certificate to be kept on file with Midway Machine. This form can be sent to you with the completed work.

CALL WITH ANY QUESTIONS: 1-715-424-2148