NEW CUSTOMER
Credit Account Application
Company Information
Company Name
*
DBA
Please complete if different than Company Name.
Employer Identification Number (EIN)
*
Please complete if different than Company Name.
Type of Account Requested
*
Charge/Credit
Credit Card
COD
Company Contact
*
First Name
Last Name
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Address (If Different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Company Contact Email
*
example@example.com
Years in Business
*
Type of Business/Industry
*
Estimated Annual Sales
*
Amount of Credit Requested
*
Accounts Payable Information
Accounts Payable Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
Accounts Payable Email
*
example@example.com
Banking Information
Financial Institution Name
*
Financial Institution Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Account
*
Checking
Savings
Other
Please complete if marked "Other"
Account Information
Will a Purchase Order or Job Number be required?
*
Yes
No
Would you like to receive Electronic Invoices & Statements?
*
Yes
No
If "Yes" please provide email
example@example.com
Reference No. 1
Business/Trade References
Do Not Submit COD References
Company Name
*
Contact Name
*
First Name
Last Name
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Type of Account
*
Charge/Credit
Credit Card on File
Other
Please specify if marked "Other"
Reference No. 2
Business/Trade References
Do Not Submit COD References
Company Name
*
Contact Name
*
First Name
Last Name
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Type of Account
*
Charge/Credit
Credit Card on File
Other
Please specify if marked "Other"
Reference No. 3
Business/Trade References
Do Not Submit COD References
Company Name
*
Contact Name
*
First Name
Last Name
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Type of Account
*
Charge/Credit
Credit Card on File
Other
Please specify if marked "Other"
Acknowledgements
Signature
*
Name
*
First Name
Last Name
Company Title
*
Today's Date
/
Month
/
Day
Year
Date Picker Icon
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