Moss Credit Application

Moss Holding Company Credit Application
Ordering From Moss Location*
Company Name*
Moss Account Representative*
DBA Names (if any)
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this location responsible for the payment of invoices?*

YesNo
If not, please list address of office responsible for payment of invoices

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Accounts Payable Contact

First NameLast Name
Accounts Payable Email
example@example.com
Accounts Payable Phone

Area CodePhone Number
Accounts Payable Fax

Area CodePhone Number
Company Type*

Sole ProprietorshipPartnershipCorporation
How many years has this business been in existence?*

0-2 Years3-5 Years6-10 Years10 + Years
D-U-N-S Number
SIC Code
NAICS Number
Tax Exempt?*

YesNo
If yes, a copy of your tax exempt or resale certificate must be attached. You may attach any other standard forms here:

Browse Files

Cancelof
Officers, Principal Owners, Parent Company, or Affiliated Companies
Name

First NameLast Name
Title
Phone Number

Area CodePhone Number
E-mail
example@example.com
Name

First NameLast Name
Title
Phone Number

Area CodePhone Number
E-mail
Trade References

Vendors with whom you do regular business on a credit basis
Reference 1: Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail
Account Number
Reference 2: Company Name
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number 2

Area CodePhone Number
Fax Number 2

Area CodePhone Number
E-mail 2
example@example.com
Account Number
Reference 3: Company Name
Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number 3

Area CodePhone Number
Fax Number 3

Area CodePhone Number
E-mail 3
example@example.com
Account Number
Authorization

I authorize Moss Holding Company to obtain credit information about our accounts as listed. Our firm is financially able to meet any sales commitments made, and agree to pay Moss Holding Company invoices according to the stated terms in return for extending credit to our company. In the event the payment is not made and this account is referred for collection, our firm will pay the cost of collection. Our firm understands interest on any unpaid balance will be charged at the highest rate authorized by law. If suit or action by an attorney is instituted, our firm agrees to pay reasonable attorney fees in said suit or action. It is understood that all billings of accounts receivables and credits are processed through Moss Holding Company headquarters in Franklin Park, IL.
Agreement and Terms*

I have read and understand the terms stated above.
Name*

First NameLast Name
Email*
Email address of the person signing the application agreement and terms.
Title*
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty:

Moss Holding Company Credit Application

Officers, Principal Owners, Parent Company, or Affiliated Companies

Trade References

Authorization