New Account Information Form

New Account Form

Please provide all required details to establish your new account
Customer Information
Company Name*
Submitted By*
Business Phone*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Tax ID Number*
Date Established*

MonthDayYear
Date
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Address (only complete if different than billing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Business*
Business
Key Contacts
Accounts Payable Contact*

Name

Email

PhoneState / Province

Postal / Zip Code
Purchasing Contact*

Name

Email

PhoneState / Province

Postal / Zip Code
Other Contact

Name

Email

PhoneState / Province

Postal / Zip Code
Transaction Details
Frequency of Business*
Frequency
MICHIGAN ONLY - If you're tax exempt, please send in Form 3372, Michigan Sales and Use Tax Certificate of Exemption. Non-Tax-Exempt companies will be charged appropriate taxes
Do you have a loading dock?*
Loading Dock
Is a liftgate service required?*
Liftgate
Do you have a forklift?*
Forklift
Is inside delivery required?*
Inside Delivery
If you are looking for credit, continue to the next set of fields. If you prefer to pay by Credit Card, this form is complete. Please complete the credit card form.
Credit Application
Amount of Credit Desired*
Please provide us with 3 Trade References.

You may upload your 3 references via the box below if applicable.
File Upload

Cancelof
Reference #1

Name

Street Address

CityState / Province

Postal / Zip Code
Email
example@example.com
Reference #2

Name

Street Address

CityState / Province

Postal / Zip Code
Email
example@example.com
Reference #3

Name

Street Address

CityState / Province

Postal / Zip Code
Email
example@example.com
Please provide us with 2 Bank References.
Reference #1

Name

Street Address

CityState / Province

Account Number
Reference #2

Name

Street Address

CityState / Province

Account Number
Has the firm or any of its principles ever been bankrupt?
Bankruptcies?
If yes, explain:
Bankruptcy Explanation
Any misrepresentation in this application will be considered evidence of fraud, since this information is the basis for the extending of credit. As an inducement to grant credit, the undersigned warrants that the information submitted is true and correct. You are authorized to investigate the credit references and principles listed.

In consideration for the extension of credit, said business promises to pay for all purchases within the terms agreed (net 30). In the event any third parties are employed to collect any outstanding monies owed by said business the undersigned agrees to pay reasonable collection costs, including attorney fees, whether or not litigation has commenced, and all costs of litigation incurred. The undersigned represents that they have the authority to execute this credit agreement on behalf of the business identified.
Business Name*
Company Name
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date
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New Account Form