Form

Company*

Physical Address

Physical Address*

City*

State*

Zip*

Mailing Address

Mailing Address*

Mailing City*

Mailing State*

Mailing Zip*

Contact Name*

Email*

Contact Phone Number*

Website*

Remittance Address

Submit invoices & backup information to granite.enviro@receiptbank.me to ensure processing.

Remittance Address*

*

Remittance State*

Remittance Zip*

Accounts Receivable Contact*

Accounts Receivable Email Address*

Regions Served

Zone 1: CT, ME, MA, NH, RI VT

Zone 2: NJ, NY, PR, Virgin Islands

Zone 3: DE, DC, MD, PA, VA, WV

Zone 4: AL, FL, GA, KY, MS, NC, SC, TN

Zone 5: IL, IN, MI, MN, OH, WI

Zone 6: AR, LA, NM, OK, TX

Zone 7: IA, KS, MO, NE

Zone 8: CO, MT, SD, UT, WY

Zone 9: AZ, CA, HI, NV, Pacific Islands

Zone 10: AL, ID, OR, WA

Service Area*

Business Information

Tax ID Number*

NAICS Code*

Describe your services*

Please upload your company W-9 & Certificate of Insurance for limit verification

W-9*

Update File

Certificate of Insurance*

Update File