Form

Company Name:*
Primary Contact:*
Title:*
Complete Address:*
Phone:*
Type of Business:*
Year Established:*
Check One:*

Individually Owned Owned Partnership Corporation
Credit Reference 1 Information
Name of Company:
Contact:
Phone:
Address:
Credit Reference 2 Information
Name of Company:
Contact:
Phone:
Address:
Credit Reference 3 Information
Name of Company:
Contact:
Phone:
Address:
Tax Exempt Information
If your organization if tax exempt, we will need a copy of your tax exemption form. You can upload it here (in pdf format only), email it, or fax it over to us at 617.848.9948.
Tax Exempt:*

Yes No
Tax ID #:
Tax Exemption Notes:
Authorization Procedure (Not Required)
Purchase Order Required?*

Yes No See Authorization Procedure
If you would like to list other Authorized individuals who can purchase on this account, please do so here, Otherwise, please explain your preference in how we authorize individuals to charge to your account (i.e. Purchase Orders, or Must be OK'd by Primary Contact... etc.)
Authorization Procedure:
Submission Information
General Terms are NET 30 Days from date of Purchase. Late Payments subject to Finance Charge of 1.5% per month. Please contact us if you would like to discuss other options. Discounts available by upfront payment. By clicking submit, you authorize Bluisma and its agents to inquire about your business and its standing. Please note any additional concerns you may have below.
Additional Notes:
Should be Empty:

Credit Reference 1 Information