Name of Legal Entity (required)
Telephone
Fax
Bill to Address (Statement will be mailed here)
Business Office Contact Person
Ship to Address (If different from above)
Exempt from Sales Tax (If yes, please complete Sales Tax Exemption Certificate) YesNo
Business Email Address
Note: Either Federal Tax ID or SSN is required.
Type of Organization Sole PropietorPartnershipCorporationLLC
State of Business Formation
Business Type O.D.M.D.OpticianWholesaleGovernment
Date of Business Formation
Choose one Federal Tax I.D. (Preferred)Social Security Number
FEID or SSN
Name
City / State / Zip
I authorize JAK Optical Laboratories and/or its related entities to obtain credit information from the above listed references and from any credit-reporting agency. I have read the Terms and Conditions as stated on www.jakopticallaboratories.com and I acknowledge that such terms and conditions govern my relationship with JAK Optical Laboratories and/or its related entities. My signature below indicates my acceptance of and agreement to those terms and conditions and my personal guarantee of Buyer's obligations.
Date
