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Credit Application Form

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Credit Application

Company Name:*
First Name*
Last Name*
Email address*
Address*
Apt, unit, bldg, fl ...
City*
Country*
Prov/State*
ZIP/Postal Code*
Phone Number*
Phone Ext
Trade Name (If different from above:)
Shipping Address (If Different:)
Fax:*
Number of Years in Business:*
Credit Limit Requested: *
Form of Ownership:*
Contact Name for Ordering:*
Title:*
Direct Phone:
Email:
Principal(s) Name:*
Principal(s) Address:*
Principal(s) Phone:
Bank:*
Account Manager:*
Bank Address:*
Bank Phone:*
Bank Fax:*
Bank Account #:*
Supplier Reference (1): Name, Contact Information, Address, Phone, EMAIL:*
Supplier Reference (2): Name, Contact Information, Address, Phone, EMAIL:*
Supplier Reference (2): Name, Contact Information, Address, Phone, EMAIL:*
Are your purchases from us PST Exempt?*

TERMS OF SALE: Our terms are NET 30 days from the date of the invoice. Interest on past dues accounts is 2% per month. Charges for collection of past due accounts will be paid by the customer. I/We hereby confirm that I/We have read and understand the terms of sale conditions. I/We confirm that all information on this application is true and correct.
Name of Authorized Signing Officer(s): *
Date:*

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Credit Application Form

Credit Application

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