New Customer Form

Legal Company Name(Required)

DBA Name (If Applicable)

Company Principal & Title(Required)

Company Principal Phone Number(Required)

Company Principal Email(Required)

Tax ID Number(Required)

Physical Address

Street Address City State ZIP Code

Payable Contact & Mailing Address

Accounts Payable Contact Name(Required)

Accounts Payable Phone Number(Required)

Accounts Payable Email(Required)

Invoices will be sent to this email.

Billing Street, PO Box City State ZIP Code

All invoices are to be paid within 15 days of the date of the invoice. If you are in need of a term extension, please list what terms you are requesting and your reasoning below.

Forms

W-9 needed from Assured Security?

Yes

Certificate of Insurance needed?

Yes

Are you tax exempt?

Yes

If yes, send ST3 to accounting@assuredsecuritymn.com

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended.

The applicant consents to the obtaining of credit and/or other information to be used at any time in connection to the account hereby applied for; and consents to and authorizes the release of any credit and financial information by any credit reporting agencies, and expressly consents to Assured Security obtaining a business credit report of the applicant for the purposes of evaluating credit worthiness.

Assured Security reserves the right, at its sole discretion and without notice, to cancel all available credit and refuse to make future advances.

Completed by Name & Title

Date

If you are a Property Management Company it is required that the next section is completed for any location you manage that we could be requested to service.

Property Management Information by Location

Do you have more than one (1) location that will require servicing?

Yes

If so, how many locations will require servicing?

More than 5 (Please send locations separately)

Physical Address (Location #2)

Location Name & Contact Street Address City, State, Zip Code Additional Information Needed for Billing

If management company, please provide the following:

Property Owner's Name

Property Owner's Phone Number

Physical Address (Location #3)

Location Name & Contact Street Address City, State, Zip Code Additional Information Needed for Billing

If management company, please provide the following:

Property Owner's Name

Property Owner's Phone Number

Physical Address (Location #4)

Location Name & Contact Street Address City, State, Zip Code Additional Information Needed for Billing

If management company, please provide the following:

Property Owner's Name

Property Owner's Phone Number

Physical Address (Location #5)

Location Name & Contact Street Address City, State, Zip Code Additional Information Needed for Billing

If management company, please provide the following:

Property Owner's Name

Property Owner's Phone Number

Please fill out the form below to be considered for an extension of credit.

*Please note that all new accounts will need to pay their first service invoice before any additional work can be scheduled.

Physical Address

Payable Contact & Mailing Address

Forms

Property Management Information by Location

Terms and Conditions - Privacy Policy

New Customer Form

Please fill out the form below to be considered for an extension of credit.

*Please note that all new accounts will need to pay their first service invoice before any additional work can be scheduled.

Physical Address

Payable Contact & Mailing Address

Forms

Property Management Information by Location

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