WELCH CUSTOMER CREDIT APPLICATION

Company or Corporate Name (If Applicable):*
State of Corporation:*
Date of Corporation:*

MonthDayYear
Date
Employer Identification #:*
Names of Principal Stockholder & Percent of Interest:*

First and Last NamePercent
Names of Corp. Officers - President/Vice President*

PresidentVice President
Names of Corp. Officers - Secretary/Treasurer

SecretaryTreasurer
Partnership or Proprietorship Name (If Applicable):
Form Of Entity:*
Name of Parent Entity:

First NameLast Name
Primary Contact:

First NameLast Name
Business Name (DBA):
Address of Partners/Individuals:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Partners/Individuals:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Desired Credit Limit:*
ServicePartsSalesRentalMillwrightMountain PowerSpecialty Products Groups
BILLING INFORMATION:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
ATTENTION:*
NAME:
Email Address:*
YesNo
YesNo
Please provide billing portal information:
YESNO
Purchase Order Contact Information:*
SHIPPING INFORMATION:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Sales Tax Jurisdiction:
Trade References: (Provide (3) Name, Address, Phone and Email)*
NAME OF BANK:*
ACCOUNT NUMBER:*
BANK INFORMATION:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
If yes, please attach a copy of your exemption certificate:

Cancelof
YesNo
YesNo
YesNo
Names of Welch employees/Branch working with:
Name/Title within your business:*

First NameTitle
Date:*

MonthDayYear
Date
Signature*

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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.
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