Credit Application

CUSTOMER INFORMATION

Company Legal Name:

Customer Type:

Please Specify:

Billing Address:

City:

State:

ZIP:

Country:

Physical Address:

City:

State:

ZIP:

Country:

Business Phone:

Cell Phone:

Billing Email Address (Required):

Company Fax:

**ALL STATEMENTS AND INVOICES ARE SENT ELECTRONICALLY TO THE BILLING EMAIL ADDRESS LISTED ABOVE.**

Type of Business:

Years in Business:

Requested Credit Line:

Legal Status:

Sole Proprietor:

Federal Tax ID#:

Date of Incorporation:

State of Incorporation:

Taxable Status:

Attach a copy of exemption certification or sales tax will be charged

One file only.
2 MB limit.
Allowed types: jpg, png, pdf, doc.

OFFICERS / COMPANY OWNERS

Officer / Owner 1

Name:

Title:

Cell / Home Phone:

Home Address:

City

State

ZIP

Date of Birth:

Driver’s License #:

State Issued:

Officer / Owner 2

Name:

Title:

Cell / Home Phone:

Home Address:

City

State

ZIP

Date of Birth:

Driver’s License #:

State Issued:

CREDIT REFERENCES

No banks, material suppliers: Only three references required

Reference 1

Name:

Phone:

Email:

City

State

ZIP

Reference 2

Name:

Phone:

Email:

City

State

ZIP

Reference 3

Name:

Phone:

Email:

City

State

ZIP

ACCOUNT PREFERENCES

Purchase Orders Required:

Job Numbers Required?

Person(s) Authorized to Purchase: