Credit Application Form
APPLY FOR NET 30 TERMS. Please allow 24-48 hours for approval and we will get back to you with any questions.
Step 1: Sales Representative Information
Date
*
-
Month
-
Day
Year
Sales Representative
First Name
Last Name
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Step 2: Business Information
Company Name
*
Contact Name
*
First Name
Last Name
Department / Position
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2 - (Suite, Unit, P.O. Box, Building, etc.)
City
Please Select
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
State
Zip Code
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Step 3: Business & Banking Information
Accounts Payable Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Corporation Type
*
Sole Proprietorship
Limited Liability Company (LLC)
S-Corporation
C-Corporation
Non-Profit
Governmental Agency
Amount of Credit Desired?
*
Federal Tax ID (EIN)
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Step 4: Banking Information
Banking Institution Name
*
Bank Account Number
Bank Routing Number
Banking Contact Name
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2 - (Suite, Unit, P.O. Box, Building, etc.)
City
Please Select
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
State
Zip Code
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Step 5: References
(You must provide 3 references)
Reference 1:
Company Name
*
Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Account Number
Reference 2:
Company Name
*
Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Account Number
Reference 3:
Company Name
*
Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Account Number
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Step 5: - Agreement Terms
By checking these boxes you are agreeing to our terms - should you have any questions please contact us.
Unless otherwise expressly provided on the credit application, payment shall be due 30 days from the date of each invoice, without discount. Any discount which may be expressly provided on the credit application hereof applies only to the sale price of the goods at the shipping point, and does not apply to any charges made for taxes, storage, loading or transportation.
*
Agree
A delinquency charge of 1-1/2 percent per month will be added to any amount due and unpaid more than 30 days from the date of the invoice billing such amount. This is an annual percentage rate of 18 percent. In the event you - the purchaser - fail to pay any amount due for any goods sold to you by us - the seller - pursuant to these general conditions of sale, you shall pay, in addition to the delinquency charge, any attorney's fees or collection fees we incur in collection of amounts so due.
*
Agree
Claims arising from invoices must be made within 7 business days of the invoice date.
*
Agree
By submitting this credit application, you authorize us to make inquires into the banking and business references that you provided.
*
Agree
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Step 6: Final Review and Signature
The terms set forth herein constitute sole terms and conditions of the contract between the purchaser and the seller. No other warranty, term condition, or understanding, whether oral or written shall be binding upon the purchaser or seller, unless hereafter made in writing and signed by the seller's authorized representative. This sale of goods and the conditions of sale shall be construed pursuant to the laws of the California
Additional Information
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of
I have read and understand the terms & conditions of this agreement.
*
Agree
Date
*
-
Month
-
Day
Year
Signature
*
Print Name
*
Title
*
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