New Customer Application Form
Primary Company Information
Domestic or International Customer?
*
Domestic (US)
International (Non-US)
Legal Business Name
*
Other DBAs (If applicable)
Legal Registered Address
*
Company Email
*
Country
*
City
*
State
List
Zip Code
*
Registered Phone Number
*
Fax Number
*
Tax/VAT ID
*
Warehouse Address Information
Is Warehouse Address Different?
Warehouse Address
Freight Information
Freight Carrier
*
Freight Account No
Logistics Contact
*
Additional Information
Customer Notes
*
Finance Contact Name
*
Finance Contact Email ID
*
Customer Sales Rep
*
Dialectic Terms and Conditions
By clicking this checkbox you agree to Dialectic Terms & Conditions.
*
Click
here
to read Dialectic's Terms & Conditions.
By clicking this checkbox you understand the Dialectic application review process.
*
Click
here
to read Dialectic's Application review process
Business Registration Copy (Domestic Customer)
Driver's License or Passport Copy (International Customer)
Copy of Federal EIN (Domestic Customer)
D.O.B Copy (International Customer)
Resale Copy (Domestic Customer)
W-9 Form (Domestic Customer)