COMPANY INFORMATION
Legal Company Name:*
DBA if any:
Owner or Officer of Company's Full Name:*
Tax ID or Registration No.:*
BILLING INFORMATION
Address:*
Address Line 2:
City:*
State:*
Zip:*
Country:*
Billing Contact:*
Billing Phone Number:*
Billing Fax Number:*
Billing E-mail:*
Credit Terms Requested:*
Credit Line Requested:*
Insurance: (While shipping on your account, do you require us to insure the shipment?)
Drop Ship: (Do you authorize us to drop ship on your behalf when specified?)
Shipping same as billing?*
SHIPPING INFORMATION (leave blank if same as billing)
Company Name:
Address:
Address Line 2:
City:
State:
Zip:
Country:
Shipping Contact:
Shipping Phone Number:
Shipping E-mail:


If you are shipping to the State of Florida, we are required to collect 7% sales tax. If you are tax-exempt in the State of Florida, please email or fax us your sales tax exemption certificate. Email: accounting@nextmicro.com or Fax: 407-814-1080

*Required Fields

Terms and Conditions

By submitting this application, the buyer agrees to be bound by the terms and conditions located at www.nextmicro.com. The buyer also affirms and attests that the information provided on this form is true and correct.