CREDIT APPLICATION

(Required for new customers only upon placement of Purchase Order.)

Firm Name:

Contact Name:

Email:

Billing Address:

Shipping Address:

City:

State:

Zip Code:

Telephone No:

Facsimile No:

Tax I.D.:

Check One:

Corporation Partnership Individual Other

Type of Business:

Year Incorporated:

Year Established:

Tax Exempt?

No Yes

Exemption No.:

Attach Copy of Certificate

Name of Owners / Partners /Officers:

Name / Title:

Address:

City, State, Zip:

(Click to add additional Owners / Partners / Officers)

Person Responsible for Accounts Payable:

Email Address:

Telephone No:

Name of Bank:

Account No:

Address:

Tel. No:

Fax No:

Bank Officer:

Purchase Order Required?

No Yes

CREDIT REFERENCES: (Please submit 3.)

Business Name:

Address:

Zip:

Phone Number:

Fax Number:

Credit Contact Email Address:

(Click to add additional references)

Please Upload Any Related Files:

Attach File

The undersigned agrees to pay all obligations extended as a result of this application for credit and it is hereby specially agreed that if such account is placed in the hands of an attorney or agency for collection or is collected by suit, or other probate proceedings, we promise to pay the principal, collection fees, and interest due plus reasonable attorney's fees together with all costs of court.

E-Signature

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