New customer application

Contractor account application

Complete the form below to apply for a CopperMoon contractor account. All information is kept confidential and used solely for account setup. We'll follow up within one business day.

Tel: (800) 727-5483Email: sales@coppermoon.com

Business information

Name of business

Type of business

In business since

Legal form under which business operates

Corporation

Partnership

Proprietorship

Resale license #(please attach certificate)

Federal tax ID #

Company website

Contact information

First name

Last name

Cell phone

Email address

Office phone

Mailing address

City

State

Zip

Shipping address same as mailing

Permission to verify

By signing below, you authorize CopperMoon Lighting, LLC to verify the business information provided in this application, including credit references and trade accounts, for the purpose of establishing a contractor account.

Signature (full legal name)

Date

901 3rd Avenue, West Point, GA 31833 · Tel: (800) 727-5483 · Email: sales@coppermoon.com

Your information is kept confidential and used solely for account setup.