New Vendor/Buyer Information Request Form

Business Name*

Contact/Representative Name*

First Last

Email Address*

Office Phone*

Cell Phone

Website

Business HQ Address*

Street Address Suite/PO Box/Building City State ZIP Code

Accounting Department Address*

Same as previous

Street Address Suite/PO Box/Building City State ZIP Code

Accounts Payable Contact

Leave blank if there’s no specific A/P contact person

First Last

Accounts Payable Email Address*

Accounts Payable Phone*

Required Document – Certificate of Insurance

If your company will be picking up materials at our job site, we must get a COI from your company naming USA Decommissioning LLC as an Additional Insured. COI must show General Liability, Auto Insurance, and Worker’s Comp coverage. Company information: USA Decommissioning LLC 9901 Brodie Ln, Ste 160-605 Austin, TX 78748 If sending COI separately from this online form, please email to accounting@usadecom.com.

Please Upload COI

Max. file size: 256 MB.

Name

This field is for validation purposes and should be left unchanged.

New Vendor/Buyer Information Request Form

Recycling Company Information Request Form

Required Document – Certificate of Insurance