Vendor Application

Complete this form to register as a Maddox Vendor

Please provide complete company, banking, and trade reference information to apply as a vendor.

Applicant

Your Name *

First Name Last Name

Job Title *

Email *

Phone Number *

Company Information

Company Name *

Company Type *

Tax ID number / EIN *

D&B number

Business Address

Address Line 1 *

Line 2

City * State *

Zip * Country *

In Business Since (year) *

Est. Annual Revenue *

Number of Employees *

Accounts Receivable Contact

AR First * AR Last *

Accounts Receivable Email *

Accounts Receivable Phone *

W-9 Form Upload

Upload W-9

Tax Exemption / Resale Certificate

Upload certificate

Bank Information

Bank Name *

Bank Address Line 1 *

Bank Address Line 2

City * State *

Postal * Country *

Bank Phone *

Trade References

Reference #1 Company Name *

First Last

Reference #2 Company Name

First Last

Reference #3 Company Name

First Last

I hereby certify that the information contained herein is complete and accurate.

E Signature *

First Name Last Name