Online Credit Application - Complete and click submit at the bottom of this form to apply for N30 (30 day) payment terms. You can also fax your own credit page, or select a printable application on the menu to the left, and fax to: 646-519-4723. Information boxes marked with and asterisk (*) require an answer.
Company Name:
*
Billing Address:
*
TEL:
*
FAX:
*
Date Started or Incorporated:
*
Estimated Annual Sales:
*
Federal Tax ID#:
*
President or Owner(s):
*
Accounts Payable Contact:
Trade Reference 1:
*
TEL:
FAX:
*
Trade Reference 2:
*
TEL:
FAX:
*
Trade Reference 3:
*
TEL:
FAX:
*
Trade Reference 4:
*
TEL:
FAX:
*
Bank 1, Name:
*
Address:
*
TEL:
*
Account#:
*
Bank 2, Name:
Address:
TEL:
Account#:
The above information is for the purpose of obtaining credit and is warranted to be true. I/we hereby authorize the firm to whom this application is made to investigate the references listed pertaining to my/our credit and financial responsibility:
*
Yes
No
Applicant's Name:
*
Applicant's Title:
*
Date:
*
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