*Required fields are in red

Company Information:
 
Company Type: 
Company Name: 
 

Billing Address:
 
Street Address: 
Suite:  City: 
State:  Zip: 
Phone: 
FAX: 
Web Address: 
 

Accounts Payable Information:
 
Contact: 
Phone:  Anticipated Monthly Expenditures:
Fax: 
Email: 
 

Shipping Information:
Same As Billing      NOTE:   If this feature is selected a Shipping County is still required.
 
Street Address: 
Suite: City:
State: Zip:
County: 
 

Names and Addresses of Individual Partners or Corporate Officers:
 
Name: 
 Address: 
Phone: 
 
Name: 
  Address: 
Phone: 
 
Name: 
  Address: 
Phone: 
 

Bank Reference:
 
Name: 
Contact: 
Acct #:  Phone #: 
 

Credit References:
 
Name: 
Phone:  Account #: 
   
Name: 
Phone:  Account #: 
   
Name: 
Phone:  Account #: 
 
 
Trade Terms: (Subject to Credit Approval): Merchandise is delivered with a packing list.  An invoice will be faxed same-day and is payable on the tenth of the following month.  An interest charge of 1.5% (18% annually) will be added to any outstanding balance on accounts not paid in full within 30 days of due date.  Any delinquent accounts turned over for collection are responsible for any and all costs associated with collection.
Name of person completing form:
Title:
Phone:
Email:


By clicking the submit button, we certify that all the information on this form is correct.  We fully understand your credit terms and agree to the proper payment in consideration of extended credit.