Credit Application

Please note that if your purchase is tax exempt, you must use the downloadable version of this form and fax a copy of your tax exempt certificate with the credit application.

Date:
Sales Rep:

COMPANY INFORMATION:
Please provide the following contact information so that we can respond to your credit application. *Indicates required fields to process credit application request.

*Company Name:
*Billing Address:
*City: *State: * Zip:
*Shipping Address:
*City: *State: *Zip:
*Phone #: ( ) Fax #: ( )
*Purchasing Manager: email:
*Accounts Payable: email:
*President or owner: email:
*How long in business:
*Will ALL your purchases be exempt from sales tax? YES NO
(If YES, please use the downloadable version of this form and fax a copy of your tax exempt certificate with the order.)
*Credit Line Requested:
*Are Purchase Order numbers required on ALL orders? YES NO

1st CREDIT REFERENCE: Name: Address: City: State: Zip: Phone Number: Fax Number:	2nd CREDIT REFERENCE: Name: Address: City: State: Zip: Phone Number: Fax Number:
3rd CREDIT REFERENCE: Name: Address: City: State: Zip: Phone Number: Fax Number:	4th CREDIT REFERENCE: Name: Address: City: State: Zip: Phone Number: Fax Number:

BANKING INFORMATION
*Bank Name:
*Address:
*City: *State: * Zip:
*Phone #: ( ) Fax #: ( )
*Contact Officer:

Applicants submission of this form attests to financial responsibility and willingness to pay our invoices in accordance with our terms of sale.