Customer Information Sheet Submit Form "*" indicates required fields Full Company Name*If a subsidiary or division of a larger organization, please also specify parent company.DBA (if applicable)Business TypeCorp, LLC, Sole Prop, or otherIn Business SinceCompany Address Street Address Suite or P.O. Box # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping Address Street Address Suite or P.O. Box # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Customer TypePrivate: Produce Distributor Institutional Meal Provider Food Manufacture Bakery Senior Feeding Machinery Medical Tools Manufacturer Cannabis Public: School District Institutional Distributor Jail Hospital Other:NOTE: The Platinum Packaging Group sends out all invoices, payment receipts, and credit memos via email (unless otherwise requested). Additional email recipients can be included on the lines provided below.Authorized Person: (Please provide either: Chief Officer or Purchasing Manager)NameTitleEmail PhoneAuthorized Person: (Please provide either: Financial Officer or Accounts Payable)NameTitleEmail PhoneAdditional Email 1 Additional Email 2 In addition to the information above, please provide a copy of: Drop files here or Select files Max. file size: 100 MB. 1. Completed W‐9 Taxpayer Identification Number and Certification Form 2. Completed Sales Tax Rules and Regulations – Resale Card/CertificateAuthorized Signature I certify that I am a representative of the above referenced company authorized to complete and submit the above information to The Platinum Packaging Group. To the best of my knowledge all information provided is correct.Printed NameTitleSignatureThis field is hidden when viewing the formSiteCAPTCHA
