Url Name Of Business Business Type Select One Sole Proprietorship Partnership Corporation LLC/LLP Federal Tax ID# Business Description / Industry Principal / Partner / Officer / Name Principal / Partner / Officer Title / Title Tax Exemption Status Yes No In what region(s) are you interested in receiving services: Shreveport Longview Dallas Physical Address Physical Address Physical Address 2 Physical City Physical State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Physical Zip Billing Address Billing Address Billing Address 2 Billing City Billing State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Billing Zip Accounts Payable Contact Accounts Payable Email Accounts Payable Phone Preferred Billing Method Mail Delivery Via US Postal Services Email Other- Documentation Must Be Attached Does your organization require a Purchase Order? Yes No Does your organization use an on-line invoicing system (i.e. Ariba, Epro, or Coupa)? Yes No Service Site Contact * Service Site Email This email address & service site contact field will be used to confirm your submission. Service Site Phone Number * How Did You Hear About Us? Web Search Referral Trade Show Direct Mail List any Payne Employee(s) you have been in contact with: Describe any current Service Requests: Submit
