CREDIT APPLICATION

Credit Application

APPLICANT INFORMATION

COMPANY NAME *

MAILING ADDRESS *

CITY *

STATE *

ZIP CODE *

SHIPPING ADDRESS *

CITY *

STATE *

ZIP CODE *

PRIMARY EMAIL *

PHONE *

FAX

TAX EXEMPT *

YES. INCLUDE TAX EXEMPT FORM

BANK REFERENCE

NAME OF BANK *

BANK ADDRESS *

CITY *

STATE *

ZIP CODE *

ACCOUNT # *

BANK CONTACT

PHONE *

TRADE REFERENCES

NAME *

ADDRESS *

CITY *

STATE *

ZIP CODE *

PHONE *

FAX

Add Reference Remove Reference

INVOICE INFORMATION

DO YOU ACCEPT EMAILED INVOICE *

YES

EMAIL ADDRESS *

CONTACT INFORMATION

POSITION

NAME *

EMAIL ADDRESS *

PHONE

ACCOUNTS PAYABLE

NAME *

EMAIL ADDRESS *

PHONE

PURCHASING

NAME *

EMAIL ADDRESS *

PHONE

Signature *

Clear

Date *

The price charged will be the price that is in effect at the time of the shipment. The terms are NET 30 days. 1-1/2% per month (18% per annum) SERVICE CHARGE will be levied for invoices not paid 15 days after the due date.

If you are human, leave this field blank.

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