New Customer Application New Customer FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4Business Information Legal Company Name *d/b/a Name (if applicable)PhoneFaxMailing Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDelivery Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeState of Incorporation *Business Type *# of Employees *Fed ID # *SIC Code *DUNS Code (if applicable)Dun & Bradstreet CodeDate EstablishedEntity Type *Has this company ever filed for bankruptcy? *NoYesDate of Bankruptcy? *Next - Contact InformationContact Information Please fill out as fully as possible - this information helps us with deliveries, billings, and general questions. AP Contact (first and last name) *Title *Email *Phone *Invoice Email *Purchasing Contact (first and last name) *Title *Email *Phone *Operations Contact (first and last name)TitleEmailPhoneReceiving Contact (first and last name) *Title *Email *Phone *Next - Delivery InformationDelivery Information Colony's operating days are M-F 8am-5pm and customers are given general delivery days to help plan and provide the best service possible. Do any of the following apply? *No dock door access - liftgate requiredDelivery appointment requiredDelivery hours differ from 7am-3pm M-FWe understand you do not have a dock door - please describe the delivery address/roadway access to your facility for deliveries. *Please specify the contact information/protocol for delivery appointments: *Please specify delivery hours Monday through Friday if different than 7am-3pm: *Next - Credit InformationOrdering Information How would you like to purchase with us? *Open Terms (preferred)Credit CardCheck / Cash in AdvanceWe understand you would like to pay by credit card or check/cash in advance - after submitting this form please call our office with payment details - 717-764-5088 - ask for our Accounts Receivables Department. Is a Purchase Order number required for us to process orders? *YesNoSign me up to order online, view past/open invoices, and purchasing history *YesNot at this timeWe're excited to have you order online withus - you will receive a seperate email with your online ordering instructions and credentials from our webmaster. Bank Information Bank Name *Phone *Contact Name *Email *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTrade References We require five credit references to establish open terms. Trade References Name *Contact *Phone *Email * Name *Contact *Phone *Email * Name *Contact *Phone *Email * Name *Contact *Phone *Email * Name *Contact *Phone *Email * File Uploads To establish an account we require your company W9. If you are tax exempt we also need a valid tax exemption form. File Upload - W9 Form * Click or drag a file to this area to upload. .pdf files only, 10 MBAre you tax exempt? *YesNoNote - if we do not receive a tax exemption certificate we will charge tax until otherwise updated. If you have mixed tax requirements please select "no" and contact our accounting department directly with your specific situation - thank you!File Upload - Tax Exemption * Click or drag a file to this area to upload. .pdf files only, 10MBSubmit