Cordeck New Credit Application

Customer Form

We request that all new customers complete the form; if you decide you'd like to apply for credit, that option is available below.
Company Name*
Name of Firm or Individual
Billing Contact*

First NameLast Name
Billing Email*
example@example.com
Billing Phone Number*
Format: (000) 000-0000.
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is your billing address DIFFERENT than your physical address?*

YesNo
Physical Address

Street Address

Street Address Line 2

CityState

Zip Code

Additional Contact Information

Rows	Full Name	Email	Phone
Purchasing
Sales
Marketing

Are you Tax Exempt and/or for Resale?*

NoYes
Please upload a copy of your Tax Certificate*

Browse Files

Cancelof
Would you like to apply for credit terms?*

YesNo

Credit Application Form

We request your cooperation in completing and returning this form to us as soon as possible so that we can review your request for credit availability.
Federal ID #*
Number of Years Established*
Number of Years at current Address*
Ownership Type*

CorporationPartnershipIndividualSole ProprietorshipGovernment
Date of Incorporation*

MonthDayYear
Date
State of Incorporation*
Type of Business or SIC #*
How many Principal Owners?*

Principals Information
Principal 1 Name*

First NameLast Name
Principal 1 Title*
Principal 1 Email*
example@example.com
Principal 1 Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Principal 1 Phone Number*
Format: (000) 000-0000.
Principal 2 Name*

First NameLast Name
Principal 2 Title*
Principal 2 Email*
example@example.com
Principal 2 Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Principal 2 Phone Number*
Format: (000) 000-0000.
Principal 3 Name*

First NameLast Name
Principal 3 Title*
Principal 3 Email*
example@example.com
Principal 3 Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Principal 3 Phone Number*
Format: (000) 000-0000.

Finance Information
Name of Bank*
Account Number*
Account Contact Name

First NameLast Name
Address of Bank*

Street Address

Street Address Line 2

CityState

Zip Code
Bank Contact Email
example@example.com
Bank Contact Phone Number*
Format: (000) 000-0000.
Bank Fax Number
Format: (000) 000-0000.

Trade References
Company 1 Name*
Company 1 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company 1 Phone Number*
Format: (000) 000-0000.
Company 1 Email*
example@example.com
Company 2 Name*
Company 2 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company 2 Phone Number*
Format: (000) 000-0000.
Company 2 Email*
example@example.com
Company 3 Name*
Company 3 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company 3 Phone Number*
Format: (000) 000-0000.
Company 3 Email*
example@example.com

Billing Information
Account Payable Contact Name*

First NameLast Name
Account Payable Contact Phone Number*
Format: (000) 000-0000.
Account Payable Email*
example@example.com

Terms & Conditions
Your Signature*

Use your cursor to draw your signature.
Your Title*
Today's Date

MonthDayYear
Date
A signed copy of this document, electronically transmitted, shall be binding and shall be deemed an original for all purposes.
Should be Empty: