Welcome to DuraComm Corporation

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Please print out this page along with the Release Authorization and Tax Exemption Certificate, fill out and fax to: Fax: (816) 472-0959 Date __________
Bill To:	Ship To:
Company Name (D/B/A) ______________________________________	Company Name (D/B/A) ______________________________________
Street Address ______________________________________	Street Address ______________________________________
P.O.Box ______________________________________	P.O.Box ______________________________________
City State Zip Code ______________________________________	City State Zip Code ______________________________________
Phone No. Fax No. ______________________________________ Email Address: ______________________________________	Fed Tax ID/ S.S. # ______________________________________ Resale Tax # / State of Issuance ______________________________________
Type of Organization ( ) Partnership ( ) Sole Proprietorship ( ) Corporation ( ) Sub Chapter S ( ) Other______________ State Incorporated: _______________________ # of Years in Business: ________________
Officers/Principals Name Title Address Phone No. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
Nature of Business ( ) Dealer ( ) Distributor ( ) OEM ( ) Self-Servicing End User ( ) Government ( ) Other
Bank References Bank Name: ________________________________________ Account No: ______________________ Address: ____________________________________________________________________________ Contact: ___________________________________________ Telephone No: _____________________
Business References Company: ______________________________________ Individual: ____________________________ Address: _________________________________________ Phone: ____________________________ City: _____________________________ State: ____________________________ Zip: _____________
Company: ______________________________________ Individual: ____________________________ Address: _________________________________________ Phone: ____________________________ City: _____________________________ State: ____________________________ Zip: _____________
Requested Credit Line: $ __________________
IMPORTANT: ACCOUNT WILL NOT BE PROCESSED WITHOUT LEGALLY AUTHORIZED SIGNATURE AND COMPLETED TAX EXEMPTION CERTIFICATE; IRS FORM 149 DuraComm Corporation 203 W. 23rd Ave. North Kansas City, MO 64116 Phone: (816) 472-5544 Fax: (816)472-0959