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General Information
Monthly Credit Desired
Are Purchase Orders Required?
Yes
No
Tax Exempt?
WA-attach State permit/Exmpt Form
CA-attach copy of Resale Certificate
No – I am not tax exempt
Number of years under current ownership
State of Incorporation
Company Information
*
Business Name
*
Doing Business As (DBA Name)
*
Billing Address
*
City
*
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
*
Zip/Postal
Country
United States Of America
Canada
Accounts Payable Contact Name
Telephone
Email Address
Legal Structure
Not Available
Sole Proprietorship
Limited Liability Company
Cooperative
Corporation
Nonprofit Corporation
S Corporation
Partnership
Limited Partnership
Type of Business
Company Net Worth
$
Length at current address
Previous address (if less than 3 years)
Persons authorized to Purchase
Has bankruptcy ever been filed?
Yes
No
If prior bankruptcy, where and when?
Have you been in business before under another name?
Yes-please provide details below
No
Prior business date, name and address
References - Trade References should be for tangible goods with companies extending similar credit limits
*
Reference Name
Phone Number
Fax Number
*
Reference Email
*
Reference Name
Phone Number
Fax Number
*
Reference Email
*
Reference Name
Phone Number
Fax Number
*
Reference Email
Bank Reference Information
*
Bank Name
*
Bank Account Number
Bank Branch
*
Bank Contact Name
Bank Contact Phone Number
*
Bank Contact Email Address
Principal / Guarantor Information
Principal Title
Principal First Name
Principal Middle Name
Principal Last Name
Principal Home Address
City
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
Zip/Postal
Telephone - Home
Principal Social Security Number (SSN)
Principal Title
Principal First Name
Principal Middle Name
Principal Last Name
Principal Home Address
City
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
Zip/Postal
Telephone - Home
Principal Social Security Number (SSN)
Attachments
If tax exempt in the state of WA, attach a copy of Washington State Resellers Permit or Manufacturing Exemption Form. If tax exempt in the state of CA, attach a copy of the completed Resale Certificate
Attachment Description
Attachment Location
Upload
Upload
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
*
Title
*
Date
PRINT AGREEMENT
*
I agree to the terms and conditions specified above.
*
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