Company InformationCompany* Address* Street Address City State / Province / Region ZIP / Postal Code Phone*FaxService Contact PhoneEmail Billing Contact PhoneEmail Account PreferencesInvoice Frequency Weekly Monthly Semi-Monthly Job Reference Required? Yes No What do you call your reference? (Job #, PO #, etc.) Invoice Delivery E-mail U.S. Mail FREE WEB ACCESS - Place orders, track, view invoices, run reportsUsername Password Payment InformationName of Card Holder Type of Card Note: For security purposes someone from our business office will contact you shortly for your credit card account informationShipping Declaration of Value (At least 5 characters, case-sensitive)In consideration of the rate charged, it is agreed that the declared value of any single shipment, whether consisting of one or more items, is not more than $100, and that the liability of NY Minute for loss or damage, irrespective of the cause of such loss or damage is limited to $100. If you would like to declare a greater value of a shipment, the value must be declared and insurance must be purchased in advance. Claims not made within 5 days shall be deemed waived by the shipper/customer. Should any claim be asserted by any third party, the shipper agrees to hold NY Minute harmless against any claims, including attorney fees, irrespective of the cause of the loss or damage. SignaturesI understand the terms stated and above authorize NY Minute to charge the credit card provided above.SignaturePrint Name Date MM slash DD slash YYYY How did you hear about NY Minute?EmailThis field is for validation purposes and should be left unchanged.