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CREDIT APPLICATION
(please print)
Billing Name Phone Fax
Information
Company E-mail
Street
City State Zip
Ship To Name
Information
(if different Company Commercial Residential
from above)
Street
City State Zip
Ownership Individual Partnership Corporation Other, explain ___________________________________
Principals
Name Address City, State, Zip
Federal I.D. Number
Years in Business
Customer 1. PO required? yes no 4. Require fax or email
Special 2. Monthly statements? yes no acknowledgments on all orders. yes no
Conditions If yes, do you want: Email Fax Mail 5. Print your part # on packing slip? yes no
(circle your If no, you will only receive invoice. How do you want to 6. Designate orders to:
choice) receive your invoice? Email Fax Mail a. ship complete / no back orders
3. Print prices on packing slip? yes no b. ship complete unless otherwise specified
(not recommended for those c. ship partials / ship back orders complete
using our drop ship program) d. ship partials / ship back orders as they come in
Bank Bank Name Address
Reference
Type of Account Account # Bank Officer’s Name Phone
Vendor
Reference Company Fax
Street Phone E-Mail
City State Zip
Company Fax
Street Phone E-Mail
City State Zip
Company Fax
Street Phone E-Mail
City State Zip
I the undersigned confirm that all information given in this application is true and correct to the best of my knowledge. I understand that terms on all purchases
are net 30 days. If this application is approved, I recognize that I/we will be responsible for any attorney’s fees and/or costs incurred in the collection of any
unpaid balance.
Signature Date