Business Information

Name of Busines _____________________________________________Years in Business____P.O. Required?________________________

Street Address ______________________________________________________________________Suite #____________________________

City____________________________ State_______________Zipcode___________________

Email address_____________________________________________

Account Contact ____________________________________(Area Code) Telephone Number _____________________Extension________

Bank Reference/Credit Card Authorization:

Bank Name_________________________________Address__________________________________________________________________

City_______________________________________________State_________

Account Number_____________________________Contact___________________________________

(Area Code) Telephone Number____________________________________________Extension______

Credit Card Type _________Account Number ________________________________Account Name _______________________________________

Expiration Date ___________Security Code___________

Authorized User Information:

Name and Title of Authorized Purchasers (Please Type or Print)

1. ____________________________________________ 2. _________________________________________
__Name __________________Title __________________Name _____________________Title

3. ____________________________________________
__Name __________________Title __________________

I certify that the above information is complete and accurate and I agree to be bound by the terms and conditions herein. I agree to
notify Wausau To Go customer service of any changes to the above information, or of any additions or termination of authorized
Users status. I hereby authorize the above the above named person to charge to our account and I understand that the above mentioned
firm is responsible for all charges incurred by authorized user(s). I hereby authorize the bank references listed to accept copies of this
application to release credit or financial information on my accounts.

__________________________________________________________________________________________________________________________
__Signature (Required)_____________________________________________________________________Title _(Required)___

__________________________________________________________________________________________________________________________
__Federal ID Number_______________________________________________________________________Date__

Terms & Conditions

You agree to allow Wausau To Go to use the information provided to conduct a credit check and you further agree to be bound by Wausau To Go
terms of credit. Upon credit approval an account will be opened. All orders on account will include 15% gratuity for the mobile waiter and a 5% billing conveniencefee. You agree to pay for all purchases charged to the account. You agree to be responsible for any outstanding balance and any new charges by authorized users.

FAX IT! 715.849.5511