Thank you for your interest in Mid-South Power Distributors. To open a COD Account, please complete the information on this page. Also, if we should not charge sales tax on your purchases, please attach legal proof of Tax Exemption such as a certificate of resale, industrial machinery certificate etc.

Company or Corporate Name (Exact Legal Name): *

Doing Business As:

Phone #: *

Fax #: *

Billing Address: City -- State -- Zip Code *

Shipping Address: City -- State -- Zip Code *

Type of Organization *

Purchasing Contact *

Accounts Payable Contact *

Purchase Order Required? *

Year of Incorporation *

Enter Year Started *

Are you a Subsidiary Or Division? *

Parent Company Name:
Telephone:
Parent Company Address including City/State/Zip: *

Enter the Names of Officers, Partners, Principals or Proprietors as appropriate:

(1) Name:

Home Address:

Phone:

(2) Name:

Home Address:

Phone:

(3) Name:

Home Address:

Phone:

***THIS APPLICATION MUST BE SIGNED BEFORE PROCESSING CAN BEGIN***

Signature of Authorized Individual *

clear

Printed Name: *

Title: *

Date: *

Upload a VALID COPY of the Resale Tax Certificates if claiming Non-Tax Status.