Customer Information Sheet
Please provide all information requested.
For questions, call 888-874-4160 or email investigate@ProspiceGroupCorp.com.
Thank you for your interest!
Customer Information Sheet
Complete Name of Company
dba
Street Address *
Mailing Address, if different *
City *
State *
Zip Code *
Work Phone
Fax # *
In Business Since (list year) *

Officers or Authorized Persons
1. Name
1. Title
2. Name
2. Title
3. Name
3. Title
Accounts Payable Contact
Name of Bank
Bank Street Address *
Bank City *
Bank State *
Bank Zip Code *
Checking Acct #
Bank Telephone # *

Trade References
Ref #1 Company
Ref #1 Account #
Ref #1 Contact
Ref #1 Phone #
Ref #1 Title
Ref #1 Date
Ref #2 Company
Ref #2 Account #
Ref #2 Contact
Ref #2 Phone #
Ref #2 Title
Ref #2 Date
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