Customer Credit Application

Please send the Resale Certificate and Sales Team Contact information along with your company information. Your form with similar information is acceptable.

If you are a new distributor, we do ask that your first order be by credit card.

Name of Company

Name of Contact

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Fax

Country

(###)

###

####

Website

http://

Date Established

YYYY

Number of Employees

Accounts Payable Contact

Bank References

1. Reference Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Account Number

2. Reference Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Account Number

Trade References (at least 3)

1. Reference Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Account Number

2. Reference Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Account Number

3. Reference Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Account Number

4. Reference Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Account Number

Line

Name of Person Providing Information

First Name

Last Name

Date

YYYY