Credit Application

Company Name:

Billing Address:
City: State: ZIP:
Shipping Address:
City: State: ZIP:
How Long in Business?
How Long At This Location? Own or Rent?
Check One:
Sole Proprietorship Partnership Corporation Individual Government LLC LLP
Type of Business:
Annual Sales Volume $:
# of Employees: Website:
Ever Filed Bankruptcy?
Yes No If Yes, Provide Date, City, and State:
Federal ID #:
Names and Titles of Two Principal Owners:

Name: Title: % of Ownership:
Name: Title: % of Ownership:

If You Are a Subsidary of Another Company List Name and Address and Phone Number:
Accounts Payable Contact Name:
AP Email: AP Phone #: AP Fax #:
Purchase Orders Required?
Yes No Verbal Acceptable: Yes No
Can Invoices Be Sent By Email?:
Yes No Email:
Are Invoices Sumbitted To a Portal?:
Yes No
Can You Check Payment Status On Portal?:
Yes No
Portal Address:

**************** TAX STATUS **************** 

If you are exempt from sales taxes? Indicate why?

What is Your State Sales Tax Exemption Number:
Parish or County Where Material May Be Recieved:

Enter the code shown below:


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