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Net Terms/Credit Application Form

To apply for Net Terms Credit, please complete and submit the following form.

NOTE: Items marked by * are required for this application to be processed.

Company Information:

Company Name: *

Billing Address: *

Billing City: *

Billing State: *

Billing ZipCode: *

Shipping Address:

Shipping City:

Shipping State:

Shipping ZipCode:

Phone Number: *

Fax Number: *

Federal ID #: *

DBA: *

Year Founded: *

Number of Employees: *

Principal Contacts:

Contact Person 1: *

Title: *

E-mail address: *

Telephone: *

Contact Person 2:

Title:

E-mail address:

Telephone:

Accounts Payable Name: *

E-mail address: *

Telephone: *

Bank Reference:

Name of Bank: *

Account #: *

Street Address: *

City: *

State: *

ZipCode: *

Phone Number: *

Fax Number:

Contact Name:

Business References:

Company Name 1: *

Account #: *

Address: *

City: *

State: *

ZipCode: *

Phone Number: *

Fax Number: *

Contact Name: *

Company Name 2: *

Account #: *

Address: *

City: *

State: *

ZipCode: *

Phone Number: *

Fax Number: *

Contact Name: *

Company Name 3: *

Account #: *

Address: *

City: *

State: *

ZipCode: *

Phone Number: *

Fax Number: *

Contact Name: *

By signing below, you are acknowledging that the above information is up to date and accurate. Should you be approved for Net Term purchasing, you will be held accountable for the conditions that apply when purchasing via Net Terms: If for any reason your account becomes past due, the entire account, regardless of any terms to the contrary, shall become due and payable immediately. All bounced checks are subject to a $20.00 processing fee and any additional charges that may apply.

Authorized Individual: *

Title: *

Date: *

Company Name: *