Thank you for your request to open an account with Dale Oxygen, Inc.In order for us to open an account, we need the following information:Company (or name if individual):*Mailing Address:*Building or Suite Number:City:*State:*Zip Code:*Shipping Address:*Building or Suite Number:City:*State:*Zip Code:*Phone Number:*Fax Number:*Email Address:*Tax Exempt #:Copy of Tax Certificate Needed for FilesEIN or Social Security #:*Contact Person in Accounts Payable:*Contact Person in Purchasing:*Puchase Order Required?*YesNoBlanket Number:Employer (if individual):What Products and Services Will You Require?*Three Trade References1. Company Name:*Address:*City:*State:*Zip Code:*Phone Number:*Fax Number:*Email Address:*2. Company Name:*Address:*City:*State:*Zip Code:*Phone Number:*Fax Number:*Email Address:*3. Company Name:*Address:*City:*State:*Zip Code:*Phone Number:*Fax Number:*Email Address:*Bank ReferenceBank:*Address:*City:*State:*Zip Code:*Phone Number:*NameThis field is for validation purposes and should be left unchanged.
