New Individual/Business Account and Credit Card Data Request

Account Type

Individual AccountBusiness Account

Account Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Fax Number

Cell Number

Email

example@example.com

Name

Attn:

Address

Street Address (and/or PO Box)

Street Address Line 2

CityState

Zip Code

Your Social Security #

Your Date of Birth

Driver's License # & State

Your Employer

Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code

Employer's Phone Number

How Long Employed

Your Position

Your Salary

Your email address

Name of Spouse

Spouse Employed By

Spouse's Social Security #

Spouse's Date of Birth

Spouse's Employer's Phone #

Nearest Living Relative

Relative's Address

Street Address

Street Address Line 2

CityState

Zip Code

Relative's Phone Number

Do you rent or own your home?

RentOwn

How long have you lived at the above address?

Previous Address

Street Address

Street Address Line 2

CityState

Zip Code

How long at previous address?

1

2

3

Last supplier of welding/safety/medical products

Contact name for sales calls

Approximately how much monthly credit will this account require?

Account Name

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Fax Number

Cell Number

Email Address

example@example.com

Name

Attn:

Address

Street Address (and/or PO Box)

Street Address Line 2

CityState

Zip Code

Purchase Orders Required?

YesNo

Are you tax exempt?

YesNo

If yes, please upload valid tax exemption forms here

Browse Files

Business Type

CorporationPartnershipProprietorshipLLC

Email

example@example.com

Date Business Was Established

Annual Sales Volume

How Long at Present Address

Federal Tax ID #

State of Incorporation

Date of Incorporation

Type of Business Your Company is Primarily Engaged in

Contact Name for Sales Calls

President/Owner #1

Home Address #1

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number #1

Controller/Owner #2

Home Address #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number #2

Own or Rent Building

Name of Landlord

Landlord's Phone #

If formerly in Business, Where and Under What Name

As of this date, I am not 60 or more days past due except with:

A petition in bankruptcy or a forced liquidation has not involved any owner, officer or individual except:

1

2

3

Company Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Fax Number

Company Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Fax Number

Company Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Fax Number

Company Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Fax Number

Upload Reference Sheet

Browse Files

Name of Bank

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Fax Number

Name of Contact at Bank

Account Number

Account Type

Last supplier of welding/safety/medical products

Approximately how much monthly credit will this account require

IMPORTANT - READ CAREFULLY

We obtain non public personal information about you to open an account with us from the following sources:

Information we receive from you on applications or other forms you complete when you want a credit account with us;
Information about your transactions with others; and
Information we receive from a consumer-reporting agency.

We restrict access to your nonpublic personal information except to Norco employees who need to know such information to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

We do not share nonpublic personal information about you without your written consent.

For the purpose of obtaining credit, I(we) warrant the above information to be true and complete, and I(we) acknowledge your terms to be net 30 days after which, if not paid, my account will be considered in default. I(we) agree to pay interest of 1.75% PER MONTH, true annual interest rate of 21% PER ANNUM on any amount 30 days past due after billing date. I(we) agree to pay reasonable attorney's fees as allowed by law if it becomes necessary to file suit to enforce collection. I hereby authorize any of the above listed credit references to provide you any information regarding their credit experience with me and authorize Norco to obtain information from a consumer-reporting agency about me.

IMPORTANT - READ CAREFULLY

For the purpose of obtaining credit, I(we) warrant the above information to be true and complete, and I(we) acknowledge your terms to be net 30 days after which, if not paid, my account will be considered in default. I(we) agree to pay interest of 1.75% PER MONTH, true annual interest rate of 21% PER ANNUM on any amount 30 days past due after billing date. I(we)agree to pay reasonable attorney's fees as allowed by law if it becomes necessary to file suit to enforce collection. I hereby authorize any of the above listed credit references to provide you any information regarding their credit experience with me and authorize Norco to obtain information from a consumer reporting agency about me.

Please sign using your mouse or touch screen*

Dated:

Date

Title

Credit Data Check

New Account Name and Address

Mailing Address

Individual Account Information

Names of Authorized Signers on Account

Billing Account Name and Address

Shipping Name & Address

Business Account Information

Names of Authorized Signers on Account

Trade Credit References

Bank Information