BusinessIQ

General Information

^*Sales Rep Name

Contractors License

Expiration Date

Customer Information

^*Company Legal Name

Doing Business As (DBA Name)

^*Tax ID

^*Street Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Billing Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Telephone - Work

Telephone - Cell

^*Email Address

^*Legal Structure

^*Are you Tax Exempt?
Yes No

^*Year Business Established

^*Do You Require A Purchase Order?
Yes No

^*Accounts Payable Contact

^*Accounts Payable Email

Accounts Payable Phone Number

Names Of Corporate Officers Partners and or Owners

^*Principal Type

^*Principal Title

^*Principal First Name

^*Principal Last Name

^*Principal Home Address

^*City

^*State/ Province

^*Zip/Postal

^*Telephone - Home

Telephone - Work

Principal Email Address

^*Principal Social Security Number (SSN)

^*Principal Drivers License State

^*Principal Drivers License Number

Principal Type

Principal Title

Principal First Name

Principal Last Name

Principal Home Address

City

State/ Province

Zip/Postal

Telephone - Home

Telephone - Work

Principal Email Address

Principal Social Security Number (SSN)

Principal Drivers License State

Principal Drivers License Number

Personal Guarantee Authorization (Y/N)
Yes No

List 3 Major Suppliers

^*Name

^*Address

^*Phone

^*Email

2nd Major Supplier

^*2nd Name

^*2nd Address

^*2nd Phone

^*2nd Email

3rd Major Supplier

^*3rd Name

^*3rd Address

^*3rd Phone

^*3rd Email

^*Invoices and Statements

Email for Invoices & Statements

Personal Guarantee

To induce WESTERN PACIFIC BUILDING MATERIALS INC. to extend credit to the named buyer and in consideration thereof, the undersigned, and if more than one, each of them, does hereby jointly and severally, personally guarantee payment of any and all invoice amounts, past-due service charges, attorney fees and all other costs and indebtedness of any kind which may now or at any time in the future be owed by Buyer and any successor thereof to WESTERN PACIFIC BUILDING MATERIALS INC.

^*Signature Of Guarantor

^*Title

^*Date

Attachments

Please attach documents relevant to the application decision process (i.e., company financials, relevant license information, etc)

Attachment Description

Attachment Location

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

^*Signature of Applicant

^*Title

^*Date

PRINT AGREEMENT

I agree to the terms and conditions specified above.

User Verification

Please complete the following by entering the value EXACTLY how it appears(case sensitive)

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