CUSTOMER CREDIT APPLICATION

CUSTOMER CREDIT APPLICATION
Corporate Name (If Applicable): *
State/Date of Corporation: *

Month Day Year
Date
Employer Identification #: *
Names of Principal Stockholder & % of Interest:
Name: *
Interest %: *
Name: *
Interest %: *
Name: *
Interest %: *
Name: *
Interest %: *
Names of Corporate Officers:
President: *
Vice President: *
Secretary: *
Treasurer: *
Partnership or Proprietorship Name (If Applicable):
General Partnership: *
Limited Partnership: *
Proprietorship: *
Treasurer: *
Name of Partner/Individuals: *
Address: *
Phone #: *
Name of Partner/Individuals: *
Address: *
Phone #: *
ARE YOU A DIVISION OR SUBSIDIARY OF ANOTHER CORP/ENTITY? Yes *

Yes No
Name of Parent Entity: *
Address: *
Phone #: *
Billing Information
Company Name: *
ATTN: *
Address *

Company Address

Street Address Line 2

City
State: *
Zip: *
Do you prefer bills to be emailed? *

Yes No
Email Address: *
example@example.com
Shipping Information
Company Name: *
ATTN: *
Address *

Company Address

Street Address Line 2

City
_ ST: *
Zip: *
Sales Tax Jurisdiction: *
Do You Require a Purchase Order? *

Yes No
Fax #: *
Trade References: (Provide Name, Address, and Phone Number) *
IF YOU ARE A TAX EXEMPT ORGANIZATION ATTACH A COPY OF EXEMPTION CERTIFICATE:
Certificate Number: *
IF YOU ARE A RESALE ORGANIZATION, LIST ALL TAX NUMBERS:
State: *
City: *
Tax ID Number : *
Have you ever Filed for bankruptcy? *
Are you in receivership? *
Has a mechanics lien been filed against you in the last 5 years? *
Welch terms are net 30 with credit approval unless stated otherwise approved. Past due accounts may be subject to a finance charge. If litigation is necessary to resolve an outstanding debt, the prevailing party shall be further reimbursed for any and all reasonable attorney fees and court costs. The understand applicant, to establish credit, furnishes the above information and warrants said information to be true, accurate, and complete. The undersigned is legally authorized to obligate the above named applicant to all the terms and conditions of sale of Welch Equipment Company. All information in this application shall be kept confidential.
Name/Title: *
Signature: *

Use your mouse, track pad or touch screen to draw your signature. Clear
*

Month Day Year
Date
Should be Empty:

CUSTOMER CREDIT APPLICATION

Names of Corporate Officers:

Partnership or Proprietorship Name (If Applicable):

Billing Information

Shipping Information