Dear Customer:

In order to properly setup your account, we require the following information about your business.

Please complete this form and fax it to New Accounts at 773-847-7502

Store Name: ___________________________________________________________

Address: ______________________________________________________________

City_______________________________ State: _______ Zip Code________________

Telephone: _________________________ Fax: _______________________________

Owner’s Name_____________________________ SSN: _________________________

Primary Contact_____________________________ Telephone___________________

Federal Tax ID Number (FEIN): ___________________________________________

Sales Tax ID Number: ________________-____________________

Please attach a copy of your State ID:

The information provided is true and correct to the best of my knowledge.

___________________________________________________ Date: ____________

Signature