Company Name Fax Application To: Or Email To:
Legal Business Name | Trade Name-DBA Phone # _________________ Fax # |
Billing Address | City State Zip Code |
Shipping Address | City State Zip Code |
Business Is a: Corporation LLC Partnership Proprietorship Year Started_____________ State of Inc. _________Federal I.D.#:__________________________________ Web Site Address:_________________________________ Dun & Bradstreet #________________________
Are You a: Subsidiary Division (if yes, check which)
Parent Company Name:________________________________ Address _______________________________ City:__________________________________________ State:_______________________ Zip:____________ Do you require a purchase order# before we accept an order? Yes No A/P Contact _____________________________A/P Email____________________________ A/P Phone__________________ Estimated Monthly Purchases. $ _____________
Terms Requested: COD Credit Card Net terms – Credit Limit Requested $_________________ Check one: Principal Partner Proprietor
Name:____________________________________________________ Social Security#__________________ Home Address:_________________________________ City:___________________ State: ___ Zip:________ Home Phone:_______________________ Mobile #______________________Email_____________________ Bank References
Name | Contact Name Phone No |
Street Address | City, State, zip Code Date Opened |
Type of Account Checking No________________ Saving No_______________ Loan No_____________ Trade References (Major Supplies)
1. Name | Contact Name Phone No. |
Street Address | City, State, Zip Code Account No. |
2. Name | Contact Name Phone No. |
Street address | City, State, Zip Code Account No. |
3. Name | Contact Name Phone No. |
Street Address | City, State, Zip Code Account No. |
You represent you are an authorized representative with authority to enter into this agreement and the information contained in this Application and any attachment is true, correct and complete. You consent to Vendor obtaining information about you personally and the Applicant from credit reporting agencies and other sources Vendor deems appropriate in considering this Application. If credit is extended, you agree to be bound by all of the terms and conditions on Vendor’s invoices and posted on Vendor’s website.
________________________________ _____________ _____________________ Signature Date Title