New Client Form

Name: Corsica Technologies
Address: 1721 Goodrich St, Augusta, GA, 30904, US
Telephone: +1(706) 722-6604

Please complete all the required fields below. You will receive an email confirmation after submitting this form confirming we’ve received your submission.

Legal Company Name ("Client") Information
Company Name*
Fed Tax ID :*
Type of Company*
Purchase Order Required*
If NPO, please submit a copy of form 501c3
Max. file size: 10 MB.
Special Tax Information
Tax Exempt?*
If yes, please submit a copy of form ST-105
Max. file size: 10 MB.
Company Address And Phone
Company Address & Phone:*
Street Address City State ZIP Code
Phone:*
Fax:
Bill To Contact Information
Bill To Address
Street Address City State ZIP Code
Bill To Email*
Additional Bill To Email Address
Additional Bill To Email Address
Bill To Phone
Bill To Fax
Accounts Payable Contact Information
Accounts Payable Contact Name:
First Last
Accounts Payable Contact Email:
Accounts Payable Contact Title:
Accounts Payable Contact Ext or DID:
Financial Department Contact Information
Financial Department Contact*
First Last
Financial Contact Title*
Email*
Contact Ext or DID:*
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Additional Locations
If your organization has multiple locations, please list those locations and their corresponding addressees below.
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Location Name:
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Location Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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Additional Locations
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All Corsica Technologies invoices will be delivered electronically to the above Bill To email address. If additional recipients are needed, please indicate in space provided. NOTE: Corsica Technologies Payment Terms are NET UPON RECEIPT. Save time and money by using our secure portal, ConnectBooster, to view, print, or pay your invoices via ACH or Credit Card. We will send you a welcome email with a link to setup an account once this form has been received.
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New Client Form

Legal Company Name ("Client") Information

Special Tax Information

Company Address And Phone

Bill To Contact Information

Accounts Payable Contact Information

Financial Department Contact Information

Additional Locations

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