HazMat Client Credit Application

HazMat Client Credit Application
Customer Information:
Company Name
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name

First NameLast Name
Contact Phone #
Please enter a valid phone number.
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name

First NameLast Name
Contact Phone #
Please enter a valid phone number.
Accounts Payable Contact Name

First NameLast Name
Phone #
Please enter a valid phone number.
Email Address to remit Invoices to
example@example.com
Years in Business
Numbers only please
Banking Information
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name

First NameLast Name
Contact Phone #
Please enter a valid phone number.
Trade References: Please attach a listing of four trade references with phone and fax
numbers.
New York State Sales Tax: Applies Exempt (If exempt, please attach exemption, resale, or direct payment certificate)

AppliesExempt
Credit Terms:
Net 30 days (US Funds). A service charge of 2% per month will be added after the due
date along with all reasonable costs and expenses, including counsel and collection
expenses incurred by Hazmat in the event of default.
Is a purchase order required?

YesNo
Certification:
We certify that all the information on this application is correct. We fully understand the
stated credit terms. In consideration of extended credit we promise to make payment
within the stated terms.
Signature

Clear
Title
Date

MonthDayYear
Date
Submit Required Attachments

Cancelof

For HazMat Use Only:

Is a credit check required? ________ If so, How much is needed? _______

How much credit has been issued? __________

Should be Empty:

HazMat Client Credit Application

Customer Information:

Banking Information