Credit Application

DELIVERY/SHIPPING DETAILS
Shipping Address *

Name of Business

Street Address

City State

Zip Code
Purchase Order (PO) Required? *

Yes No
Delivery Details *
Please specify hours in which your business can receive deliveries and any special delivery instructions.

ACCOUNTS PAYABLE INFORMATION
Name *

AP First Name AP Last Name
AP Contact Information *

AP Email AP Best Phone Number
AP Receipt Billing *

AP Email for Billable Statement AP Email for Billable Invoice

PAYMENT DETAILS
Terms Requested *

COD Credit Card on File Net 30 Other
Payment Method *

Check Credit Card on File Electronic Check ACH Other
Do you already have a sales rep with us? If so, enter their name below.
Sales Rep

TRADE REFERENCES
Trade References Company A Details

Trade References Company Name

Street Address

City State

Zip Code
Trade References Company A Contact Information *

Trade References Email Trade References Best Phone Number
Trade References Company B Details *

Trade References Company Name

Street Address

City State

Zip Code
Trade References Company B Contact Information *

Trade References Email Trade References Best Phone Number

AGREEMENT
I/We certify that the above information is true and correct and I/We agree to pay this account in accordance with your credit terms. In the event I/we should not be able to pay in accordance with your credit term, this is your authority to charge a finance charge of 1.5% per month (or a minimum charge of 75 cents for balances under $35.00) calculated on the last day of each month, on the balance as of the last day of the previous month (less payments and credits to said balance) until payment is made in full. This represents an annual percentage rate of 18%. I/We authorize you to verify this information and/or obtain additional information from a credit-reporting agency.
Printed Name & Title. Please note, this application must be signed by owner or officer.

Name Title
E-Signature *

Application must be signed by owner or officer. Clear
Date Signed *
Should be Empty:

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