Credit Application
Payment Terms: Net 30 Days
 
New Customer Information
 
A/P Contact Name: 
Company Name: 
   
Phone: 
Email: 
Fax: 
 
Billing Information Shipping Information
   
Company Name: 
Billing Address: 
City: 
State: 
Zip: 
Country: 
Company Name: 
Shipping Address: 
City: 
State: 
Zip: 
Country: 
 
Other  
   
Federal ID#: 
State ID#: 
DNBC/SIC Code: 
Is Your Company a: 
Date Business 
Established: 
Type of Business: 
No of Employees: 
Tax Exempt: Yes No
  Note: If Tax Exempt in the States of TX, we must have a Tax Exempt Certificate on file.
   
If Corporation, then  what state? 
President/Owner: 
Zip: 
A/P Contact: 
 
Bank Reference
 
Bank Name: 
Account#: 
Fax #: 
  Checking Savings
Contact Person: 
Phone#: 
Email: 
 
Trade References
 
Ref#1 Ref#2
Company Name: 
Address: 
City/ST: 
Contact: 
Phone: 
Fax: 
Email: 
Company Name: 
Address: 
City/ST: 
Contact: 
Phone: 
Fax: 
Email: 
 
Ref#3 Ref#4
Company Name: 
Address: 
City/ST: 
Contact: 
Phone: 
Fax: 
Email: 
Company Name: 
Address: 
City/ST: 
Contact: 
Phone: 
Fax: 
Email: 
 
Authorized Signature for release 
of credit information: