Credit Application

Credit Application
Company Name*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Accounts Payable Contact
Name*
Email*
example@example.com
Requested Payment Terms*

Net 30CODCredit Card
Credit References are required for Net 30. Payment terms granted are based on credit worthiness.
Where would you like your invoices emailed?*
example@example.com
Shipping Information
Same as billing address?

Yes
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
UPS Account Number (if applicable)
Preferred LTL Carrier:
LTL Carrier Account Number:
If not shipping collect, truck shipments will be sent prepaid and added.
Trade References

Please provide at least 3 references.

provide reference information +
Company Name (1)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Company Name (2)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Company Name (3)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
What is your tax status?*

TaxableTax Exempt
What type of business are you?*

End-UserDealerOEM
Please upload W-9 and Tax Exemption Information/Resale Certification

Browse Files

Cancelof
We certify that the above information is true and correct. I/We agree to pay this account in accordance with the credit terms established above. We authorize Mid-State Sales Inc. to verify this information and or obtain additional information by securing data from a credit agency.*

Agree
Signature

Clear
Printed Name*
Date

MonthDayYear
Date
Title*
Rev. 06/20 Form 7101.99
Should be Empty:

Shipping Information