Reimagyn – New Client Application

New Client Application

1. Company

2. Contacts

3. References

4. Authorization

Welcome to Reimagyn

To get started as a Reimagyn client, please complete this short application. All fields marked with * are required. The form takes approximately 5–10 minutes.

Company Information

Company Name

Address Line 1

Address Line 2

Country

State / Province

ZIP / Postal Code

Website

Tax ID #

Contact Information

Accounts Payable Contact

Contact Name

Phone Number

Email Address

Purchasing Contact is the same as Accounts Payable Contact

Purchasing Contact

Contact Name

Phone Number

Email Address

Business References

Please provide two business references that can verify your company's creditworthiness and payment history.

Reference 1

Company Name

Contact Name

Phone Number

Email Address

Address Line 1

Address Line 2

Country

State / Province

ZIP / Postal Code

Reference 2

Company Name

Contact Name

Phone Number

Email Address

Address Line 1

Address Line 2

Country

State / Province

ZIP / Postal Code

Authorization & Signature

I consent to the above authorization

Yes, I consent No, I do not consent

Authorized Signatory

First Name

Last Name

Title / Position

Phone Number

Email Address

Date

Signature

Draw your signature in the box below

Sign here

✓

Application Submitted

Thank you for applying to become a Reimagyn client. Our team will review your application and follow up within 2–3 business days. Please keep your reference ID for your records.

Welcome to Reimagyn

Application Submitted

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