Credit Application

Business Name (Legal Name):

Business Trade (DBA) Name:

Billing Address:

Billing Street Address (Required):

Billing City (Required):

Billing State (Required):
ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Billing Zip Code (Required):

County:

Billing Phone (Required):

Shipping Address 1:

Shipping Street Address (Required):

Shipping City (Required):

Shipping State (Required):
ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Shipping Zip Code (Required):

County:

Shipping Phone (Required):

Shipping Address 2:

Shipping Street Address:

Shipping City:

Shipping State:
ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Shipping Zip Code:

County:

Shipping Phone:

Shipping Address 3:

Shipping Street Address:

Shipping City:

Shipping State:
ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Shipping Zip Code:

County:

Shipping Phone:

Federal ID # (Required):

Date Established (Required):

Description of Business (Required):

Sales Tax (If NO, Please provide exemption certificate via upload.):
YesNo

Accounts Payable Contact (Required):

Name (Required):

Phone (Required):

Email (Required):

How would you like to receive invoices & Statements? (Required):
MailE-mailPortal

Quotes & Acknowledgements Contact

Name (Required):

Phone (Required):

Email (Required):

Principal Owners/Officers (Required):

Bank References

Bank Name (Required):

Bank Location (Required):

Bank Contact (Required):

Bank Phone (Required):

Trade References

Trade Reference 1:
Name of Company (Required):

Address/City/State/Zip (Required):

Company Email or Phone (Required):

Trade Reference 2:
Name of Company (Required):

Address/City/State/Zip (Required):

Company Email or Phone (Required):

Trade Reference 3:
Name of Company (Required):

Address/City/State/Zip (Required):

Company Email or Phone (Required):

Terms: Terms are net 20 days from invoice date. A 1.5% per month or 18% per annum service charge will be levied on all invoices 30 days past due. All accounts with credit lines that choose to pay invoices at their due date with a credit card will be charged a 3% fee.

The undersigned agent has the authority to bind the company to 1) Pay all invoices within previously indicated credit terms. 2) Pay all service charges levied on past due invoices. 3) Pay upon demand all collection cost and expenses of collection, including but not limited to collection fees and/or attorney fees at a rate not to exceed 50% of the amount sought for collection together with service charges at the rate of 1.5% per month or 18% per annum. 4) Authorize the contact of any of the above credit references regarding credit standing.

Authorized Signature (Required):

Date: (Required):