Submit New Application

Facility Account Information Application

To be approved to submit purchase orders, please complete and submit this form, ensuring you include your billing contact’s information.

Name

Phone

Alt Phone

Administrator

Mailing Address

Address

City

State

Zipcode

Facility Information

Sponsoring Facility

Training Program

Facility Name

Billing Contact Information

BILLING FACILITY NAME (IF DIFFERENT FROM FACILITY NAME)

BILLING MAILING ADDRESS

BILLING CONTACT NAME

BILLING EMAIL (for invoice to be sent)

BILLING PHONE NUMBER

Affidavit

Facility agrees to D&S Diversified Technologies-Headmaster Net 30 credit terms. Past-due invoices will be assessed a 1.50% late fee per month. Accounts that are past due more than 90 days will be put on a payment upfront process and will not be allowed any further credit.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.