BusinessIQ

Credit Requested

^*Estimated Annual Purchases
$

^*Credit Limit Requested
$

Sales Rep Name

Company Information

^*Business Name

Doing Business As (DBA Name)

^*Billing Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Billing Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Shipping Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Accounts Payable Contact Name

^*Telephone

^*Email Address

^*Application Contact Name

^*Telephone - Work

^*Application Contact Email Address

Name of Purchaser

Purchaser Phone Number

Purchaser Email

Email Invoices To

Years In Business

Legal Structure

^*Tax Exempt (Yes or No)

Customer Class (i.e. Retail, B2B, Team)

Trade Reference Information

Reference Name

Reference Account Number

Phone Number

Reference Email

Contact Name

Phone Number

Contact Email

Reference Name

Reference Account Number

Phone Number

Reference Email

Contact Name

Phone Number

Contact Email

Bank Name

Bank Account Number

Bank Contact

Bank Contact Phone Number

Bank Contact Email Address

Principal / Guarantor Information

Principal Title

Principal First Name

Principal Last Name

Principal Home Address

City

State/ Province

Zip/Postal

Telephone - Home

Principal Social Security Number (SSN)

Attachments

IMPORTANT: PLEASE NOTE that an Exemption Certificate and or Multi-Jurisdiction Form is required, covering each state shipped to, if Tax Exempt. Also please enclose a copy of your latest financial statement to assist in our review.

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

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