Customer Information Sheet

Customer Information

Company Legal Name*

Date of Ownership*

Company DBA or Trade Name

Website

Primary Contact First Name*

Primary Contact Last Name*

Primary Contact Email*

Primary Contact Phone*

Billing Information

Billing Contact First Name*

Billing Contact Last Name*

Billing Contact Email*

Billing Contact Phone*

Billing Address*

Billing City*

Billing State*

Billing Zip Code*

Purchasing/Shipping Information

Purchasing Contact First Name

Purchasing Contact Last Name

Purchasing Contact Email

Purchasing Contact Phone

Shipping Address (if different from Billing Address)

Shipping Address

Shipping City

Shipping State

Shipping Zip Code

Fax Number

Preferred Billing Method*

Business Structure

Business Type*

Incorporation Date

Incorporation State

Resale No.

Federal ID No.

Business Activity & Products

Primary Business Activity / Product Lines Carried*

Purchase Rasmussen Gas Logs, FireBalls, etc?*

Yes No

Purchase Solaire Infrared Grills?*

Yes No

Purchase Bromic Patio Heaters?*

Yes No

Principal / Partner / Officer #1

Name & Title*

Percentage Owned*

Phone Number*

Address*

City*

State*

Zip Code*

Principal / Partner / Officer #2

Name & Title

Percentage Owned

Phone Number

Address

City

State

Zip Code

Authorization & Agreement

We/I hereby warrant that the information on this form is true, accurate, and complete. We/I promise to provide Rasmussen with complete and updated information as soon as that information is known. We/I promise to pay for all purchases in accordance with Rasmussen’s terms of sale as indicated on each invoice and in the dealer/distributor policies.

If at any time payment is not made when due, we/I agree to pay service charges at the rate of 1½% per month (18% annual rate) on any past due amount. In the event collection proceedings are necessary, we/I agree to pay all incurred charges and expenses including attorneys’ fees and court costs.

By signing below, we/I certify that we/I have the full power and authority to act for the above-named entity and accept all of the above terms and conditions.

I have read and agree to the terms and conditions above.*

Principal / Partner / Officer*

Title*

Date*