Industrial Products - Credit Application

Please fill in the information below to the best of your abilities. When you have finished click on the Submit button at the bottom of the page.

Once you have submitted the form it will be processed by our Credit Department and a representative will call you with in the next 24 hours.

If you have any questions or if you prefer to complete our credit application by fax

please call 1-800-345-8207

Your full name:

Your email address: (e.g.: you@aol.com)

Today's Date:

Company Name:

Owner

Years In Business:

Phone Number:

Fax Number:

Accounts Payable Manager Name:

State of Incorporation:

Billing Address (Street, City, State, Zip, Country):

Ship to Address (Street, City, State, Zip, Country):

Product(s) you are interested in purchasing:

Property:
Owned
Rented

Type of Business:

Number of Full Time Employees:

Number of Part Time Employees:

Credit Limit Requested:

Anticipated Annual Purchase:

Bank Reference

Bank Name:

Bank Address (Street, City, State, Zip, Country):

Account Number:

Check this box if you prefer to give us your Account Number over the phone when we call to verify your information.
Will Give Account Number Over Phone

Bank Phone Number

Bank Contact Name:

Trade References

Please list below four (4) firms with which you have done business with over the last year.

Trade Reference 1 (Company Name, Street Address, City, State, Zip, Phone, Fax, Contact Name):

Trade Reference 2 (Company Name, Street Address, City, State, Zip, Phone, Fax, Contact Name):

Trade Reference 3 (Company Name, Street Address, City, State, Zip, Phone, Fax, Contact Name):

Trade Reference 4 (Company Name, Street Address, City, State, Zip, Phone, Fax, Contact Name):