Please complete the following Credit
Application Form. We will respond to your application generally
within 1 business day. However, if you prefer a more rapid response time
or a different method of contact, please contact us directly via:
Check Here if you
have an order pending or if you are requesting immediate processing
of this application.
Date
Account Executive
Amount Requested
(numbers only, no $ sign)
Name of Business (DBA)
Type of Business
Corporation or Other Name
Street Address
Street Address 2
County
City
State
Zip /
Postal
Primary email address
Billing Address
(required only if other than
above)
Street Address
Street Address 2
County
City
State
Zip /
Postal
Business Phone
(please include area code)
Business Fax
(please include area code)
Name of Accounts
Payable Contact
Accts Payable Phone
(please include area code)
Accts Payable Fax
(please include area code)
Are P.O.'s used?
Tax Exempt Status
Date Business Started
(MM/DD/YYYY)
# of Employees
Expected Annual Sales
(numbers only, no $ sign)
Bank
Name
Bank
Branch
Account Officer
Bank Phone
Business Checking
Account Number
Name /
Position of Officers, Partners, Owners or Other Responsible Parties
(if none other, please leave
blank)
Name
Position
Name
Position
Name
Position
Name
Position
Dun & Bradstreet #
List Four
Principal Suppliers With Whom You Have Maintained Credit For A
Minimum Of One Year (Full
name, address, phone, fax)
1
Company Name
Street Address
Street Address 2
City
State
Zip /
Postal
Phone
(please include area code)
Fax
(please include area code)
2
Company Name
Street Address
Street Address 2
City
State
Zip /
Postal
Phone
(please include area code)
Fax
(please include area code)
3
Company Name
Street Address
Street Address 2
City
State
Zip /
Postal
Phone
(please include area code)
Fax
(please include area code)
4
Company Name
Street Address
Street Address 2
City
State
Zip /
Postal
Phone
(please include area code)
Fax
(please include area code)
THIS APPLICATION MUST BE DIGITALLY "SIGNED"
BELOW, TO BE PROCESSED
I
agree to this form of digital signature:
(If you
select "No" a representative will contact you to establish
credit)
For the purpose of establishing credit with
creditor, I/We the undersigned, warrant the financial information
below to be true, correct and complete to the best of my/our
knowledge and hereby authorize any credit investigation needed for
verification.
(digital signature)
(If you
select "No" we will not attempt to establish credit)
TERMS: NET 30 DAYS
Read before providing digital
signature / approval:
If credit is extended, I/We agree to pay all
debts incurred within the terms of sale and/or invoice.
However, should the debt become past due, I/We expressly agree to
pay finance charges on the past due amount at the rate of 1 1/2%
per month (18% annual rate). I/We further expressly agree to
pay reasonable collection costs and/or attorney's fees incurred in
connection with the collection of this account.
Name
(MUST BE AN OFFICER OR OWNER)
Title
I/We Agree (Digital Signature)
(If you
select "No" a representative will contact you to establish
credit)
