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General Information
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You are applying for?
Desert Industrial Gas
California Tool & Welding Supply
Serv-O-Tek
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Type of Business?
Partnership
Sole Proprietor
INC
LLC
S Corp
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FEDERAL ID
Please do not add any dashes in the phone number
Company Information
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Business Name
Doing Business As (DBA Name)
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Physical Address
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City
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State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
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MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
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WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
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Zip/Postal
Country
United States Of America
Canada
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Billing Address
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City
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State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
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Zip/Postal
Country
United States Of America
Canada
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Telephone - Work
NAICS Code
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Year Business Established
Trade Reference Information
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Reference Name
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Phone Number
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Type of Industry?
Restaurant
Fabrication
Education
Hotel
Hobby
Water Filtration
Construction
Military
Manufacturing
Automotive
Laboratory
Agriculture
Aerospace
Party Supply
Medical
Distributor
Other
Please do not add any dashes in the phone number
Bank Reference Information
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Bank Name
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Bank Account Number
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Bank Branch
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BANK ACCOUNT IN NAME OF
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SIGNED BY:
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Is the business name on the top of the form the exact match to your credit information?
Yes
No
N/A
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Name of Person completing profile
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Accounts Payable Name
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Email Address
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Purchasing Contact Name
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Are Purchase Orders Required?
Yes
No
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Are you renting cylinders?
Yes
No
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Are Statements required?
Yes
No
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Email address to receive invoices
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Is the billing address the delivery too?
Yes
No
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If NO, please write delivery address
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Delivery location hours?
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Contact for deliveries:
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Phone (do not add dashes):
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Is there any special instruction?
Collateral
Collateral Market Value
$
Ownership Stake in Collateral
Attachments
The following information is for the purpose of obtaining credit and goods or services sold pursuant to this application shall be on the terms and conditions set forth and this application shall become a part of all future contracts whether written, oral or mixed.
Attachment Description
Attachment Location
Upload
Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.
Terms and Conditions
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Signature of Applicant
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Title
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Date
PRINT AGREEMENT
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I agree to the terms and conditions specified above.
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User Verification
Please complete the following by entering the value EXACTLY how it appears(case sensitive)
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