Credit Application

Please allow 5 business days for response.

Please note: all items are required to be completed unless you have a standard reference form to submit. If you have a standard reference form, only fill out the items noted (*=required) then jump ahead to the bottom of the form to attach your standard reference form.

*(denotes required field)

Company Information

Name of Firm or Individual *

Street Address

City, State, Zip

Phone Number *

Fax Number

Type of Organization

Corporation
Partnership
Proprietorship

State of Corporation

Federal I.D. #

How long have you been in business?

Describe Your Business *

Contact Information

Accounts Payable Contact 1 (include email) *

Accounts Payable Contact 2 (include email) *

List all Officers or Partners *

Bank Information

Bank Name

Phone #

Account #

Contact

Address

City, State Zip

List 3 Trade References

(1) Name/Address/AR Contact/Phone & Fax

(2) Name/Address/AR Contact/Phone & Fax

(3) Name/Address/AR Contact/Phone & Fax

Almost Done...

Amount of credit requested *

Under $1000
Under $5000
Over $5000

I agree that all the information on this form is correct and fully understand credit terms are net 30 days. Past due accounts will be charged 1.5% per month (18% annual rate) on the past due balance. Shipments will not be made to accounts over 45 days. Orders will be placed on hold at 60 days and credit will be terminated at 75 days. We further agree to be liable for all legal fees on invoices referred to a collection agency or attorney.

I have read and agree to these terms *

Name and title of person submitting the form *

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Credit Application

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