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 Name Last Name
Billing Email *
example@example.com
Billing Phone Number *
Billing Address *

Street Address

Street Address Line 2

City State

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

Yes No
Physical Address

Street Address

Street Address Line 2

City State

Zip Code

Additional Contact Information

	Full Name	Email	Phone
Head of Marketing
Head of Sales
Head of Purchasing

Are you Tax Exempt and/or for Resale? *

No Yes
Please upload a copy of your Tax Certificate *

Browse Files

Cancel of
Would you like to apply for credit terms? *

Yes No

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 *

Corporation Partnership Individual Sole Proprietorship Government
Date of Incorporation *

Month Day Year
Date
State of Incorporation *
Type of Business or SIC # *
How many Principal Owners? *

Principals Information
Principal 1 Name *

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

Street Address

Street Address Line 2

City State

Zip Code
Principal 1 Phone Number *
Principal 2 Name *

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

Street Address

Street Address Line 2

City State

Zip Code
Principal 2 Phone Number *
Principal 3 Name *

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

Street Address

Street Address Line 2

City State

Zip Code
Principal 3 Phone Number *

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

First Name Last Name
Address of Bank *

Street Address

Street Address Line 2

City State

Zip Code
Bank Contact Email *
example@example.com
Bank Contact Phone Number *
Bank Fax Number *

Trade References
Company 1 Name *
Company 1 Address *

Street Address

Street Address Line 2

City State

Zip Code
Company 1 Phone Number *
Company 1 Email *
example@example.com
Company 2 Name *
Company 2 Address *

Street Address

Street Address Line 2

City State

Zip Code
Company 2 Phone Number *
Company 2 Email *
example@example.com
Company 3 Name *
Company 3 Address *

Street Address

Street Address Line 2

City State

Zip Code
Company 3 Phone Number *
Company 3 Email *
example@example.com

Billing Information
Account Payable Contact Name *

First Name Last Name
Account Payable Contact Phone Number *
Account Payable Email *
example@example.com

Terms & Conditions
Your Signature *

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

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