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Request for a Tompkins Account

Complete this form and click "Submit" below. The fields in bold are required

BILL TO:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
Check if Shipping Matches Billing
SHIP TO:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
**PLEASE PROVIDE AT LEAST 3 CREDIT REFERENCES**
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
NOTE: IF YOU LIVE IN CA, IA, KS, MO, NC, OH, PLEASE FAX A STATE SALES TAX EXEMPTION FORM. YOU WILL BE CHARGED TAX IF NOT PROVIDED.

STATE SALES TAX EXEMPTION #:

YEARS IN BUSINESS:

BANK:

Security Verification
To complete the form's submission, please answer the following:

3 + 4 =