Phipps Credit Application Form

Application for Credit and Agreement to Credit Terms
Company Name*
Phone Number*
(555) 555-5555
Primary Contact E-mail*
example@example.com
Company Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years in Business*
Number of Employees*
Industry*
Concrete; General Contractor; Flooring; etc.
Primary Phipps location:*

ClevelandColumbus (MTR)CantonToledoOut of State Customer
How did you hear about us?

Business and Credit Info
Credit Limit Desired*
Accounts Payable Contact*

First NameLast Name
A/P Phone Number*
(555) 555-5555
E-mail*
example@example.com
Company Bill To Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Invoicing Preferences (select all that apply):

P.O. / Job Name Required on InvoicesPrint Pricing on Pick Ticket
Would you like to make payments via ACH? If yes, we will email you an ACH form.*

YesNo
Tax Exempt Status (check one)*

TaxableNon-Taxable
If Non-Taxable, upload tax exempt form

Browse Files

Cancelof
Authorized Persons and Additional Contacts:
1.    Full Name   Email      Phone Number   Title


2.    Full Name   Email      Phone Number   Title


3.    Full Name     Email      Phone Number   Title

Agreement

Credit Terms
By submitting this application for credit, the applicant certifies that all information provided is supplied willingly and is correct. The applicant authorizes The Chas E. Phipps Co. to contact all references provided in order to verify the information supplied herein and to establish the creditworthiness of the credit applicant.
Terms and Conditions*
Type Name*

First NameLast Name
Signature*
Title*
Signature Date*

MonthDayYear
Date
Should be Empty:

Application for Credit and Agreement to Credit Terms