Individual/Business Name:

Street & Box Address Line 1:

Street & Box Address Line 2:

City, State, Zipcode:

Business Phone:

Fax Number:

Cell Phone Number:

Pager Number:

Driver's License Number:

Social Security Number:

Type of Business:

Please select one of the following:

Proprietorship Partnership Corporation Personal

Form of Payment:

Cash      Credit Card      Check

Name of Bank:

Mail this page to:
I. D. Booth Inc / Booth Electrical Supply
Wholesalers
620 William Street, P.O. Box 579
Elmira, NY 14902-0579

Attention: Credit Manager