WELCH CREDIT APP

CUSTOMER CREDIT APPLICATION
CORPORATE NAME (IF APPLICABLE)
STATE OF CORPORATION*
State*
DATE OF CORPORATION*

MonthDayYear
Date
EMPLOYER IDENTIFICATION #*
NAMES OF PRINCIPAL STOCKHOLDER & PERCENT OF INTEREST
Name*
Ownership Interest*
Name
Ownership Interest
Name
Ownership Interest
Name
Ownership Interest
PARTNERSHIP OR PROPRIETORSHIP NAME (IF APPLICABLE)
General PartnershipLimited PartnershipProprietorship
NAME, ADDRESS, PH# OF PARTNERS/INDIVUALS
NAME, ADDRESS, PH# OF PARTNERS/INDIVUALS
YesNo
NAME OF PARENT ENTITY
ADDRESS/PHONE PARENT ENTITY
Format: (000) 000-0000.
PRIMARY CONTACT PARENT ENTITY
BUSINESS NAME (DBA) PARENT ENTITY
Desired Credit Limit*
PartsServiceSalesRentalMillwrightMountain PowerSPG
Billing Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE #*
Format: (000) 000-0000.
ATTN*
YesNo
EMAIL ADDRESS*
example@example.com
Shipping Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do You Require A P.O.?*
SALES TAX JURISDICTION*
State, County, and City Tax Jurisdiction
FAX #
Email Invoices?*
TRADE REFERENCES: (PROVIDE NAME, ADDRESS, AND PH)*
BANK INFORMATION:
NAME*
ADDRESS*
PHONE NUMBER*
Format: (000) 000-0000.
ACCOUNT NUMBER*
IF YOU ARE A TAX EXEMPT ORGANIZATION, ATTACH A COPY OF EXEMPTION CERTIFICATE:
CERTIFICATE NUMBER
File Upload

Cancelof
IF YOU ARE A RESALE ORGANIZATION, LIST ALL TAX NUMBERS:
STATE
CITY
TAX ID
YesNo
YesNo
YesNo
WELCH TERMS ARE NET 30 WITH CREDIT APPROVAL UNLESS STATED OTHERWISE APPROVED. PAST DUE ACCOUNTS MAY BE SUBJECT TO A FINANCE CHARGE. IF LITIGATION IS NECESSARY TO RESOLVE AN OUTSTANDING DEBT, THE PREVAILING PARTY SHALL BE FURTHER REIMBURSED FOR ANY AND ALL REASONABLE ATTOURNEY FEES AND COURT COSTS. THE UNDERSIGNED APPLICANT, IN ORDER TO ESTABLISH CREDIT, FURNISHES THE ABOVE INFORMATION AND WARRANTS SAID INFORMATIONTO BE TRUE, ACCURATE, AND COMPLETE. THE UNDERSIGNED IS LEGALLY AUTHORIZED TO OBLIGATE THE ABOVE NAMED APPLICANT TO ALL THE TERMS AND CONDITIONS OF SALE OF WELCH EQUIPMENT COMPANY, INC. ALL INFORMATION PROVIDED IN THIS APPLICATION SHALL BE KEPT CONFIDENTIAL.
NAME/TITLE*
SIGNATURE*

Clear
Date*

MonthDayYear
Date
WELCH EMPLOYEE/BRANCH WORKING WITH*
Should be Empty:

CUSTOMER CREDIT APPLICATION

Billing Information

Shipping Information

BANK INFORMATION:

IF YOU ARE A TAX EXEMPT ORGANIZATION, ATTACH A COPY OF EXEMPTION CERTIFICATE:

IF YOU ARE A RESALE ORGANIZATION, LIST ALL TAX NUMBERS: