(Credit Application)
Company Name: _________________________________________________________
Type of business: _________________________________________________________
Business mailing address: __________________________________________________
City: ____________________________________ St: _____ Zip: _______________
Business shipping address: _________________________________________________
City: ____________________________________ St: _____ Zip: _______________
Accounts Payable contact: ________________________________________
Telephone: ___________________________ Fax: __________________________
E-mail address: ________________________________________
Do you require a monthly statement: ____ Yes ____ No
Statement mailing address: ___________________________________________________
City: ____________________________________ St: ____ Zip: _______________
Federal ID #: _____________________ Do you require a purchase order: ___ Yes ___ No
Are your purchases tax exempt: ____ Yes ____ No
(if yes, please provide a copy of your exemption certificate along with this credit application)
Do you require authorized persons to make purchases: ____ Yes ____ No
Names:
______________________________________ ___________________________________
______________________________________ ___________________________________
Requested Credit Limit: $ ________________
Name of your banking institution: _____________________________________________
Address: ____________________________________________________________
Phone: ___________________________
Trade References (3 required):
Name: _______________________________________________________
City, St: _____________________________________________________
Phone: _________________________ Fax: _________________________
Name: _______________________________________________________
City, St: _____________________________________________________
Phone: _________________________ Fax: _________________________
Name: _______________________________________________________
City, St: _____________________________________________________
Phone: _________________________ Fax: _________________________
Company Officers or Principals:
Name: ____________________________________________________________
Title: _____________________________________________________________
Address: __________________________________________________________
City, St Zip: __________________________________________________
Phone number: ______-________-____________
SS #: _______-_____-____________
Name: ____________________________________________________________
Title: _____________________________________________________________
Address: __________________________________________________________
City, St Zip: __________________________________________________
Phone number: ______-________-____________
SS #: _______-_____-____________
Name: ____________________________________________________________
Title: _____________________________________________________________
Address: __________________________________________________________
City, St Zip: __________________________________________________
Phone number: ______-________-____________
SS #: _______-_____-____________
Credit Terms:
Payment is due 30 days from the date of invoice and may be subject to late charges or finance charges. This account will be an open balance account and not a revolving charge account.
By signing this credit application, you agree to our terms and authorize Howard Supply Company to obtain credit information needed to establish an open account.
Authorized Signature: ______________________________________ Date: _______________
Print name: ____________________________________________
Title: __________________________________________________
Please return signed credit application to:
Howard Supply Company
Attn: Credit Department
1745 S. Loop
Casper, WY 82601
307-265-8539
Fax: 307-473-5332