Credit Application

Company Name:*

Enter the company name.

Website:

Enter the company website address.

Contact Name:*

Enter the Primary Contact person (please include First & Last name).

Email Address*

Enter the contact email address

Billing Address 1:*

Enter the first line of your billing address.

Billing Address 2:*

Enter the second line of your billing address.

Billing Address 3:

Enter the third line of your billing address.

Billing City:*

Enter the city of your billing address.

Billing State:*

Enter the State of your billing address.

Billing Zip Code:*

Enter the Zip Code of your billing address.

Primary Phone Number:*

Enter the main phone number for your company. (you may enter an extension if applicable)

Shipping Address 1:*

Enter the first line of your shipping address.

Shipping Address 2:*

Enter the second line of your shipping address.

Shipping Address 3:

Enter the third line of your shipping address.

Shipping City:*

Enter the city of your shipping address.

Shipping State:*

Enter the State of your shipping address.

Shipping Zip Code:*

Enter the Zip Code of your shipping address.

Ship to Contact Name:*

Enter the Primary Contact person for shipping/receiving (please include First & Last name).

Ship to Phone Number:*

Enter the phone number for the shipping/receiving contact at your company. (you may enter an extension if applicable)

Type of Business:*

What type of business are you.

Bank Name:*

Enter the name or your bank.

Bank Address:*

Enter the Address for your bank (please include full address, any missing information will delay your application)!

Contact Person for your account:*

Enter the Primary Contact person at your bank.

Checking Account Number:*

Enter your checking account number.

Purshase Order # Required?*

Are Purchase Order numbers required? (check one box)

Yes

No

Purchases Tax Exempt?*

Are Purchases Tax Exempt? (check one box)

Yes

No

Accounts Payable Contact*

Enter the Accounts Payable Contact person (Full Name).

Accounts Payable Phone Number:*

Enter the phone number for Accounts Payable Department. (you may enter an extension if applicable)

Federal ID EIN #:*

Enter your Federal ID EIN #:

Sales Tax Exemp #:

Trade Reference 1:*

Enter Company Name, Contact, Address, Phone, Fax, & Account # for this trade reference

Trade Reference 2:*

Enter Company Name, Contact, Address, Phone, Fax, & Account # for this trade reference

Trade Reference 3:*

Enter Company Name, Contact, Address, Phone, Fax, & Account # for this trade reference

Agreement*

1. That you are authorized to release the information contained in this form.
2. I/We authorize the above listed references to release credit information concerning our account.
3. I/We agree to conform to the published terms of the Vendor and to pay all collection expenses incurred by the Vendor in collecting past due amounts.
4. You authorize us to contact your bank & trade references listed about your credit history.

Check Here

Additional Information:

Yes