ONLINE CREDIT APPLICATION

Company Name

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

Contact Person

BANK REFERENCE

Bank Name

Phone

(###)

###

####

Contact Person

Account Number

CREDIT REFERENCES

Business Name

Phone

(###)

###

####

Fax

(###)

###

####

Business Name

Phone

(###)

###

####

Fax

(###)

###

####

Business Name

Phone

(###)

###

####

Fax

(###)

###

####

Authorized Signature

Terms are net 30. If it becomes necessary to effect collections, I (we) will pay reasonable attorney fees, court cost, and interest at 1.5% per month. If my (our) business is a corporation, the undersigned agrees to be personally responsible for any purchases made by the corporation pursuant to this application.

Agreement to Use Electronic Signatures

I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document.

Title of Authorized Signee

Date

YYYY

Time

Hour

Minute

Second

Credit Application

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