100 E. Santa Anita Avenue

Burbank, CA 91502

p: 818) 276.1130

f: 818) 842.2150

w: http://www.laraghouse.com

e: info@laraghouse.com

New Customer Information Form

 

General Information

Fields with Asterisks (*) are required

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Business Type *

Primary Person's Contact Information

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Shipping Address

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Name of Person(s) Authorized to Place Orders On Behalf Of Company

*

Resale Information

Are you a reseller?

Upload CA Resale Certificate
(Maximum file size 1MB, PDF Only please)

Download an Adobe Reader fillable version.
Print, scan and select this file or upload your own:

Section 6378 Tax Exemption

Do you have a partial tax exemption under Section 6378?

Upload Section 6378 Exemption Certificate
(Maximum file size 1MB, PDF Only please)

Download an Adobe Reader fillable version.
Print, scan and select this file or upload your own:

Billing Information

Billing Address

Same as mailing? *

NOTE: These fields are inactive if "YES" is selected in the previous field. If you would like to submit different billing address and contact information, please select "NO" in the previous field.

   

Credit Information and Card Authorization

Upload proof of insurance (Maximum file size 1MB, PDF Only please)
Choose a file to upload:
Card Type

Credit Card Expiration Date

 /   / 

Los Angeles Rag House Rental Agreement

By entering your name in the "Signature" field below you hereby acknowledge that you have read and agree to all terms contained in the Los Angeles Rag House, Inc. Rental Agreement. A copy of this document will be sent to the Primary Contact Person's email address.

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Why do I have to do this?