Vendor Account Information Request

Please complete this form to establish a vendor account with Digital Table Advertising.

Vendor Name(Required)

Primary Contact Name(Required)

First Last

Title(Required)

Email(Required)

Tax Identification Number (TIN)(Required)

Bank Name(Required)

Account Holder Name(Required)

Account Number(Required)

Routing Number(Required)

Bank Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature

Signed by(Required)

Date(Required)

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