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MID-SOUTH POWER DISTRIBUTORS, INC.
ACCOUNT SET-UP FORM
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):
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Doing Business As:
Phone #:
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Fax #:
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Billing Address: City -- State -- Zip Code
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Shipping Address: City -- State -- Zip Code
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Type of Organization
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Corporation
Partnership
Sole Proprietorship
Purchasing Contact
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Accounts Payable Contact
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Purchase Order Required?
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YES
NO
Year of Incorporation
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Enter Year Started
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Are you a Subsidiary Or Division?
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Yes
No
Parent Company Name:
Telephone:
Parent Company Address including City/State/Zip:
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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
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clear
Printed Name:
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Title:
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Date:
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Upload a VALID COPY of the Resale Tax Certificates if claiming Non-Tax Status.
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3250 MILLBRANCH -- MEMPHIS, TN 38116 -- PHONE: 901-396-0710 -- FAX: 800-552-3280