1122 N. State Street, Bellingham, WA, 98225
Phone:  (360) 738-1280 Account #
Fax:  (360) 738-0864
Personal Information
Applicant's Name: Position / Title:
Business Name:             
Address: City: State: Zip:
Billing Address: City: State: Zip:
Type of Business: UBID #:
How long in business under present membership?           Years   Months
How long at present location?           Years   Months
Previous address if less than 1 year at present location:
Address: City: State: Zip:
Tax Exempt # (If applicable, attach tax exempt certificate)

Ownership Corporation Partnership Proprietorship Nonprofit Individual

Person(s) to contact regarding billing:
Approximate number of copies per month:
Bank Account
Name: Account #: Phone:
Address: City:  State: Zip:
Credit Reference
Name of firm:  Address:  Phone: 
Name of firm:  Address:  Phone: 
Persons authorized to charge the account
1. Name: Signature: 2. Name: Signature:
3. Name: Signature: 4. Name: Signature:
5. Name: Signature: 6. Name: Signature:

Terms of credit and payment: Normal payment terms are net 15 days from the date of billing. Extend term available with approval on qualified accounts. Past due accounts are subject to 15 % interest per month (18% per year). Purchaser is liable for any collection fees or legal assistance charges required to collect all due bills. There will be a $3.50 service charge per month if the balance is less than $10.00. The undersigned certifies that all the information on this application is true to the best of his/her knowledge; and that undersigned fully understands and agrees to the proper payment and said terms.

Applicant's Signature:  Title:
For Office Use Only
Pending Approved  Signature:  Date: