Credit Application


  Sales Rep Name:
Account#
COMPANY BILLING INFORMATION (to be filled out for all account types)
Company's Legal Owner:

   Company D.B.A Name:
Street Address (Billing):
 A.P.Contact: Telephone:
City:

 State Zip Code:
A.P. E-mail Address Fax:
Street Address (Shipping):
 Buyer Contact: Telephone:
City:

 State Zip Code:
Buyer's E-mail Address: Fax:
Type of Business (Check one)



Type of Bussiness (Check one or More)




Type of Account Requested (Check one or more) $




Company Website Address:  
D & B Duns # Date Business Started
State Tax License #
 Federal Tax ID #
         
NAME AND ADDRESS OF OWNERS & OFFICERS (to be filled out for all account types)
Owner's Name (1)
 Title (if Corp.)

   Owner's Name (2)
 Title (if Corp.)
Street Address (Billing):
 Street Address (Billing):
City:

 State Zip Code:
City:

 State Zip Code:
Years w/Company
 Date of Birth
Social Sec. # (N/A if Corp.)

 Years w/Company
 Date of Birth
Social Sec. # (N/A if Corp.)
E-Mail Address: Telephone:
 E-Mail Address: Telephone:
         
VENDOR TRADE REFERENCES (to be filled out for all account types)
Vendor Name:
Contact:
 Telephone:
Type of Account (Check one) Credit Limit :
Account #

 Fax:
Vendor Name:
Contact:
 Telephone:
Type of Account (Check one) Credit Limit :
Account #

 Fax:
Vendor Name:
Contact:
 Telephone:
Type of Account (Check one) Credit Limit :
Account #

 Fax:
         
AGREEMENT
         
Authorized Signature:
 Print and Title:
 Date:

         
         
TERMS AND CONDITIONS OF SALE (to be filled out for all account types)
         
         
Authorized Signature:
 Print and Title:
 Date:

         
STATE BLANKET CERTIFICATE OF RESALE (to be filled out for all account types)

Name of Purchaser:

     
Street Address:
   Zip Code: Country:  
City:
 State  
         

I HEREBY CERTIFY:


      

That I Hold Valid State Seller's Permit Number:

   

Expiration Date of Permit (if applicable):

   
         
Authorized Signature:
 Print and Title:
 Date:

         
CREDIT CARD AUTHORIZATION FORM ***(For those applying for a Credit Card Payment Account only)
Type of Credit Card (Check one) : Credit Card # Expiration Date:

Is this Credit Card an ATM Debit Card? Issuing Bank: Bank Customer Service #
         
CREDIT CARD BILLING STATEMENT INFORMATION

Name on Credit Card:

  Security Code:
Street Address:      
City: State: Zip:
Country:      
         
BANK REFERENCE FORM (for those applying for a net or COD Account only)
Business Account Name: Account Number:  
Name of Financial Institution: Branch Name:  
Branch Contact Name: Branch Phone:  
Branch Fax:      
         
Applicant Signature: Applicant's Bank Account: #