AMS - Prepay Account Application Form

Legal Business Name:

DBA / Trade Name:

Street Address:

City:

State:

Zip/Postcode:

Primary Contact Name:

Title:

Telephone:

Mobile:

Email Address:

Federal Tax ID #:

State Sales Tax ID #:

Type of Business:

Length of Time in Business:

Business Website or Social Media Page:

A/P Contact Name:

A/P Contact Phone:

A/P Contact Fax:

AP Contact Email Address:

Statement Email Address (if different from the above):