First Name *

Last Name *

Company

Street Address *

Address 2

State *

City *

Postcode / Zip *

Phone *

Which type of customer are you?* ---Select--- Distributor Consumer Corporate Customer

Type of business. Please select one. * Corporation Proprietorship Partnership Limited Liability Other

Date business started *

State Tax Exemption number *

Company total sales last year *

Anticipated sales this year

Total Assets *

Total liabilities *

Total assets and liabilities as of *

Current credit rating from Dun & Broadstreet, TWR, other

Expected monthly purchase from TPS (please provide best estimate). *

Select the TPS categories you will be ordering: * Tape Door Handles Touch Screen Overlays Counter Top/Sheets Custom Applications