STEVEN MARSILI SALES

NEW ACCOUNT FORM

      Please  fax  to:  888-314-1393

BusinessName:____________________________________________

BillingAddress:____________________________________________ City:________________State:____________Zip:________________

Business:_______________________________________

Phone #:________________Fax #:_______________

E-mail Address:_______________________________

WebAddress:_________________________________ 

Contact Person:________________________________

Resale #_____________Business License:___________  

(copy must be attached)                                                   ( copy must be attached)

 Years  In  Business:_______________

Ship to Name:_____________________________________________

Address: _____________________Residence or Business:__________ 

City:_________________State:___________ Zip:_____________

 Phone:_______________________ Fax:_____________________

Special Instructions:______________________________________

Credit  Card  Type:  Mc  ___  Visa___  Am  Exp___

Credit  card  #  _____________________________________________

Exp. Date:______________________________ Sec. Code: _____

Billing  Address:   __________________________

   __________________________

   __________________________

Signature:  ______________________________