Credit Application

Company or Proprietor’s Name *

Resale No

Credit Amount Requested *

FED. Tax ID

City *

State *

Zip Code *

Phone Number *

Fax Number

Purchasing Contact Name *

Purchasing Contact Email

Account Payable Email

Account Payable Phone Number

Date Established

Estimated Annual Sales

Owner

Address

Owner

Address

One trade reference is required in order to process this form.

Trade References:

Vendor *

Street Address *

Phone Number *

Fax Number

Account # *

Years of Account *

Vendor

Street Address

Phone Number

Fax Number

Account #

Years of Account

Vendor

Street Address

Phone Number

Fax Number

Account #

Years of Account

Bank References:

Checking Account

Bank

Phone Number

Fax

Years of Account

Savings Account

Bank

Phone Number

Fax

Years of Account

Terms and Conditions:

The above information is submitted by the undersigned for the purpose of obtaining credit. If deemed necessary, financial statements of the undersigned may be requested for review.

The undersigned agrees to pay all invoices within our standard payment term of net 30 days. Accounts over 30 days past due are subject to a late payment charge of 1.5% per month. A $30.00 fee will be charged for all returned checks.

Additionally, the undersigned agrees to pay all collection costs and related attorney’s fees, if account becomes delinquent and collection proceedings become necessary.

*The undersigned authorize the release of credit information as requested by seller:

We hereby certify the foregoing to be true and agree to the above term:

Term Agreement *

Yes, I agree.

First Name *

Last Name *

Date * +