MTAC INDUSTRIALSOLUTIONS New Client Application Name(Required) First Last Phone(Required)Email(Required) Corporate Name(Required)Doing Business As(Required)Please check applicable label: Corporation LLC Partnership LP Proprietorship Federal Tax no.State where registeredAL : AlabamaAK : AlaskaAZ : ArizonaAR : ArkansasCA : CaliforniaCO : ColoradoCT : ConnecticutDC : District of ColumbiaDE : DelawareFL : FloridaGA : GeorgiaHI : HawaiiID : IdahoIL : IllinoisIN : IndianaIA : IowaKS : KansasKY : KentuckyLA : LouisianaME : MaineMD : MarylandMA : MassachusettsMI : MichiganMN : MinnesotaMS : MississippiMO : MissouriMT : MontanaNE : NebraskaNV : NevadaNH : New HampshireNJ : New JerseyNM : New MexicoNY : New YorkNC : North CarolinaND : North DakotaOH : OhioOK : OklahomaOR : OregonPA : PennsylvaniaRI : Rhode IslandSC : South CarolinaSD : South DakotaTN : TennesseeTX : TexasUT : UtahVT : VermontVA : VirginiaWA : WashingtonWV : West VirginiaWI : WisconsinWY : WyomingPrinciple business activitiesYears in businessFormer name (if applicable)Year of most recent ownership changeBy By acquisition? By Merger? Previously filed bankruptcy? Yes No Physical Location Address (facility to be serviced)(Required) Street Address City State / Province / Region ZIP / Postal Code Business Telephone Number Site Purchasing/Procurement Information Purchasing Contact NamePurchasing Contact Location (if not the same) Street Address City State / Province / Region ZIP / Postal Code Purchasing Contact Email Address Purchasing Contact Phone Number Corporate Accounts Payable Information AP Billing Address Street Address City State / Province / Region ZIP / Postal Code Corporate AP Contact Name(Required)Corporate AP Contact Location (if not the same) Street Address City State / Province / Region ZIP / Postal Code Corporate AP Contact Email Address Corporate AP Contact Phone NumberMTAC will Email invoices to example@example.comDo you pay via ACH?Bank that payment will be drawn fromBank Address Street Address City State / Province / Region Note: A Purchase Order is REQUIRED for EVERY project I certify that the information above is true and correct as of the date below. I understand that MTAC Industrial Solutions is a Net 30 company and invoices will be paid accordingly, unless otherwise arranged with MTAC Industrial Solutions. Invoices not paid Net 30 will be subject to a late fee.Printed Name(Required)Authorized SignatureTitlePhoneDate(Required) MM slash DD slash YYYY If any of the above information changes, please advise AR@MTACIS.COM immediately, so that we don't have issues sending and processing invoices and payments. Change Order Fee Acknowledgement MTAC institutes a change order fee for all quoted work that is tied to a given PO, and has been modified, schedule changed, or otherwise interrupted. Please note that a Purchase Order is REQUIRED for EVERY project. This fee will be applied any time and every time there is a significant change to the scope of work involved in a project after the project is scheduled or already underway. All additional labor and materials required for any changes will be billed on a T&M basis and can then be added to the existing purchase order or can be quoted, and an additional purchase order can be issued to cover that additional quote. The change order fee will be in addition to these charges and will cover administrative costs as well as the costs associated with the disruption of our work schedule. This fee will also be applied any time the job site conditions are such that the work cannot be completed in a safe or timely manner, as quoted, or as agreed upon during the set-up project. The change order fee will be $500.00 and the client will be made aware of the additional fee before any work is performed that would require the addition of this fee. Once again, this fee is in addition to the cost associated with the changes to the original job scope. We appreciate the opportunities we have to assist you with the variety of tasks we perform at your location(s). We are sure you can appreciate the consequences of changes to our schedule or your site conditions that warrant additional time or labor to complete the project as compared to how it was quoted and planned. Our goal is to avoid this situation by good planning, and follow-through on both sides of the agreements we make. Thank you for the opportunities to assist you, we appreciate your business.Printed NameSignature (Change Order Fee Acknowledgement.)This Is To Verify That You Agree To Our Change Order Fee Acknowledgement.Date MM slash DD slash YYYY To Whom it May Concern: MTAC Industrial Solutions, Inc. would prefer to receive payments for invoices via ACH. If ACH is an option, please utilize the following information to send payments: Checking Account Old National Bank - Evansville, IN Routing Number: 086300012 Account Number: 104330805 Please send payment remittance confirmations to AR@MTACIS.COM. Please don't hesitate to contact me with any questions at 317-936-6822. Regards, Jen Poynter HR Manager OwnershipAre you a publicly-traded entity or are you owned by one? Yes No If Yes, ticker symbolTrading exchangeIf privately held, name of owner holding controlling interestAdditional owners (if no single individual has controlling interest)Name of Parent if you a subsidiary of another privately-held company Trade References (Furnish a minimum of three with complete information) Company Name; City, State, Zip; Phone # / Fax #; Account #Company Name; City, State, Zip; Phone # / Fax #; Account #Company Name; City, State, Zip; Phone # / Fax #; Account #Company Name; City, State, Zip; Phone # / Fax #; Account #Company Name; City, State, Zip; Phone # / Fax #; Account #This application completed by:Printed name Signature (Trade References)TitleEmail Phone NumberDate MM slash DD slash YYYY W-9 FormMax. file size: 256 MB.NameThis field is for validation purposes and should be left unchanged.
