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New Account Application
Fill out the below form to request a new account application.
"
*
" indicates required fields
Who is requesting this account?
First Name
*
Last Name
*
Title
*
Email
*
Phone Number
*
Cell Number
*
Company Name
*
Company Shipping Address
Shipping Street Address
*
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*
State
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Shipping Contact Name
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Billing Street Address
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City
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*
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California
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Tennessee
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Wisconsin
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Yukon Territories
Postal Code
*
Billing Contact Name
*
Billing Contact Email
*
Billing Contact Cell
*
Other Information
Which brand of dispensers do you typically service?
*
Gilbarco
Wayne
Other
What is the total number of service technicians working for your company?
*
1-5
5-10
10-15
Greater than 15
Are you or your technicians trained and certified in:
*
Gilbarco
Wayne
Verifone
Veeder-Root
Radiant
Other
Are you a:
*
Service Provider
Distributor
Convenience Store Owner
How many Certified Pump technicians do you have?
*
What is your projected dollar amount to be spent with Freedom?
*
$5000 – $10,000
$10,000 – $50,000
$50,000 – $100,000
$100,000+
Are you prepared to place an initial order for a minimum of $500?
*
Yes
No
Do you need a Sales Rep to call you?
*
Yes
No
Do you have any tax exemption status in any state in the U.S.?*
*
Yes
No
States with Tax Exemption
*
Select all states that apply. Please email exemption certificates prior to placing orders to accountsreceivable@freedomelectronics.com
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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