Mark C. Pope Associates, Inc.

Billing

Please provide details on your billing location

Company Name

Billing Address

City

State

Zip Code

Phone Number

Federal ID Number

Dun & Bradstreet Number

Shipping

Please provide details on your physical / shipping location

Shipping address is same as billing

Shipping Address

City

State

Zip Code

Phone Number

Contact Information

Please provide contact information for anyone that may be involved in accounts payable.

Contact Name for Accounts Payable

Email

Phone

Purchase Orders

Does your company require purchase orders for services?

Purchase Orders are required

Invoices

How would you like to received your invoices

Receive a physical invoice mailed to your billing address

Email a copy of the invoice

Sales Tax

Is your company exempt from sales tax

Our company is tax exempt

Trade References

Please include below a list of at least 3 references we may contact that you have done business with in the past 12 months. Be sure to include the name and contact information of someone in that company’s accounts receivable or credit department.

I would like to upload a file instead

1

Company Name

Address

City

State

Zip Code

AR Contact Name

Phone

Email

2

Company Name

Address

City

State

Zip Code

AR Contact Name

Phone

Email

3

Company Name

Address

City

State

Zip Code

AR Contact Name

Phone

Email

Acknowledgement of Terms

Please review and provide your acknowledgement of terms required by Mark C. Pope Associates, Inc.

Credit terms are 30 days from date of invoice: subject to credit approval. Outstanding balances are subject to 1.5% per month interest. Any charges incurred by MCP for invoice submission may result in additional fees. The undersigned authorizes and releases all companies listed on this application to furnish information and/or check credit.

I acknowledge and accept the terms defined above.

Name

Title