Credit Application Form
Billing & Shipping Information
Company Name
*
DBA
Bill To Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Ship to Address
*
Same as Billing Address
Different Ship to Address
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Business Information
Check one:
*
Corporation
Partnership
Proprietorship
Subsidiary of
Division of
Years in Operation
*
Type of Business
*
A/P Manager Name
*
A/P Manager Contact Email
*
example@example.com
A/P Manager Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prepay/Line of Credit
*
Prepay
Credit Line Requested
Requested Net 30 Line of Credit
*
Requested Net 30 Line of Credit
Tax/Resale Certificate
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Authorized Buyer
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Buying Group Affiliation
DUNS#
Preferred Collect Carrier
Account Number
Additional Document(s)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Bank Information & Trade References
Bank:
Contact Name:
Account No.
Phone:
Complete Bank Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Trade References
Reference 1 Company Name:
*
Reference 1 Contact:
*
Reference 1 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1 Email:
*
example@example.com
Reference 2 Company Name:
*
Reference 2 Contact:
*
Reference 2 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 Email:
*
example@example.com
Reference 3 Company Name:
*
Reference 3 Contact:
*
Reference 3 Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3 Email:
*
example@example.com
Customer’s Authorization to Release Bank and Trade Information
Attention Bank and Trade References: Please provide information on all accounts listed as well as any loan information. I/We hereby authorize you to whom this application is made, or your agents, to investigate my/our credit worthiness and will provide financial statements, tax returns etc., as you deem necessary.
Title:
Prepared By:
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Customer Contact Information
Purchasing Contact:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
To Receive Order Confirmations
Order Confirmation Email 1:
*
example@example.com
Order Confirmation Email 2 (Optional):
example@example.com
Order Confirmation Email 3 (Optional):
example@example.com
To Receive Shipping & Tracking Information
Shipping & Tracking Email 1:
*
example@example.com
Shipping & Tracking Email 2 (Optional):
example@example.com
Shipping & Tracking Email 3 (Optional):
example@example.com
To Receive Invoices
Invoice Email 1:
*
example@example.com
Invoice Email 2 (Optional):
example@example.com
Invoice Email 3 (Optional):
example@example.com
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Sales Leadership Contact
Name
*
First Name
Last Name
Email
*
example@example.com
*
I approve of receiving emails from Majestic Glove in the future
Position
*
Market Segment(s) Served
*
Preferred Communication Channel
*
Email
Phone
Video Call
Other
Estimated Annual Safety Spend
*
Business Contacts for New Products, Pricing, & Promos
Contact Email 1
*
example@example.com
*
I approve of receiving emails from Majestic Glove in the future
Contact Email 2 (Optional)
example@example.com
I approve of receiving emails from Majestic Glove in the future
Contact Email 3 (Optional)
example@example.com
I approve of receiving emails from Majestic Glove in the future
Ecommerce Admin Contact
The eCommerce Admin is responsible for managing their organization’s account, including setting up or deactivating users, assigning roles and permissions, and editing shipping details. They can also view and approve requisitions, access invoice and order history, approve or manage saved orders, and add, edit, or remove items from the wishlist. Additionally, they have full access to company-specific pricing.
Name
*
First Name
Last Name
Email
*
example@example.com
Majestic Sales Representative
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