Credit Application

Business Information

Business entity name *

Group Name (If part of group or DBA)

Bill To Address

City

State / Province

Zip / Postal Code

Ship To Address

City

State / Province

Zip / Postal Code

Phone *

Fax

Email *

Website

Name of owner

In business since

Tax Exemption #

EIN #

Corporation

Partnership

Limited Liability

Email addresses

Order Confirmation

Tracking Information

Invoices

Accounts Payable and Credit Information

Accounts payable contact name

Phone #

Email

Alternate accounts payable contact name

Phone #

Email

Business/Trade References

Company name

Contact name

Address

Phone

City

Zip / Postal Code

Email

Company name

Contact name

Address

Phone

City

Zip / Postal Code

Email

Bank Info

Name

Phone

Address

Acct #

City

State / Province

Zip / Postal Code

Signature

Print name