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Credit Application

Credit Application

COMPANY INFORMATION
Company:*  
Billing Address:*  
City:*  
Country:  
State:*  
Zip:*  
Shipping Address:*  
City:*  
Country:  
State:*  
Zip:*  
Type of Business:  Corporation  Partnership  Sole Proprietorship
Year Est. of Incorporated:*  
SIC Code:*  
PROCUREMENT INFORMATION
Accounts Payable Contact:*  
Phone:*  
Fax:*  
Parent Company:*  
City:*  
Country:  
State:*  
Zip:*  
Does Your Company Use
Purchase Orders Forms? 		 
Sales Tax Exemption Number:*  
 (Ohio, California, Washington, and Utah companies claiming
  exemption must attach a copy of exemption certificate)
BANK INFORMATION
Name of Bank:*  
Phone:*  
Fax:*  
Name of Bank Officer:*  
Account Number:*  
DUN &BRADSTREET D&B Number:*  
D&B Rating:*  
TRADE REFERENCES
(Minimum of three references required. References will be contacted by phone)
REFERENCE:*  
Phone:*  
Account Number:*  
REFERENCE:  
Phone:  
Account Number:  
REFERENCE:  
Phone:  
Account Number:  
TERMS & CONDITIONS
All invoices are mailed at the time of shipment, with payment terms Net 30. Any account determined to be delinquent will be placed on Hold status until all past due balances are remitted. A late fee of 1.5% will be applied to all past due balances. The undersigned agrees that all costs incurred in collection of delinquent accounts will be charged to the above named applicant. Signature also authorizes Bank and Trade References to release account information.
 
Authorized Person's Name:*  
Title:*  
Date:  
CNS Representative’s Name:  
Terms:  
Sales Person:  
Taxable:  Yes   No
Special Requests:  
  *I Agree with Terms and Conditions.
    
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