New Customer Application

New Customer Application
Full Name*

First NameLast Name
Company*
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Accounts Payable Email*
example@example.com
Paperless Invoices (Email)

Yes, enroll me in paperless invoices (email)
Company Website*
www.yourwebsite.com
Estimated Monthly Purchases*
$10,000
Year Established*
1957
# of Employees*
25
Provide a brief description of your company's primary industry and business activies.*
Resale Permit or Sales Tax Number*
(Note: Miller Edge will only collect sales tax for shipments to Pennsylvania and Arizona, but require tax-exempt forms for all states at the time of application, if applicable.)
Sales Tax Exempt*

YesNo
If yes, please attach a copy of sales tax exempt form:

Cancelof
Payment Type Requested*

VISAMasterCardTermsCheck in Advance
If applying for terms, please click the Credit Application field below to complete the entire application.

Credit Application
Terms

Complete only if applying for terms
Type of Business:

Sole ProprietorPartnershipCorporation
SS/n or Employer Identification Number (EIN)
Owner Name
John Doe
Owner Email
jdoe@companyname.com
Authorized Buyers
Buyer Name
Title
Email
example@example.com
Buyer Name
Title
Email
example@example.com
Buyer Name
Title
Email
example@example.com
Bank or Savings and Loan Association
Bank/Association Name
Account Number
Branch Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank/Association Name
Account Number
Branch Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicants' Principal Suppliers

Please list at least three
Company
Contact Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company
Contact Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company
Contact Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has applicant or any of its officers ever filed a voluntary petition of bankruptcy?

YesNo
If yes, please explain:
Has a tax lien, civil suit, or involuntary bankruptcy petition been filed against applicant or any officers within the last six (6) years?

YesNo
If yes, please explain:
PAYMENTS: In consideration of Miller Edge (Our Company) extending credit to the applicant, the Applicant agrees to pay for all items delivered and services rendered to, or at the request of, the applicant, in accordance with the terms of each invoice. The Applicant agrees that each of the terms and conditions of sale stated on the invoices shall be a term of the contract for each sale from Our Company to the applicant. The Applicant acknowledges that a monthly interest charge of 1.5% per month (or the maximum legal interest rate, if lower) shall be applied to all sums due to Our Company that have not been paid by the 30th day of the month following billing, and the Applicant agrees to promptly pay said interest charge. An additional interest charge, computed on the same basis, will be due and payable every 30 days thereafter. Waiver of any one or more interest charges shall NOT be deemed to be a waiver of future interest charges. The Applicant further agrees that regarding such service charges, the Applicant and Our Company are parties to a written commercial contract. Should it become necessary to place the account with a collection agency or attorney, the Applicant agrees to pay all collection costs and attorney fees in addition to all other sums due. The Applicant authorizes Our Company to obtain credit and financial information concerning the Applicant at any time and from any source. The undersigned warrants that the above agreement has been carefully read and that the Applicant understands it completely.

New Customer Application

Terms

Authorized Buyers

Bank or Savings and Loan Association

Applicants' Principal Suppliers

Finalize Application