Page 3 - Strybuc-2020-Catalog
P. 3

CREDIT APPLICATION
                                                            (please print)
            Billing     Name                                       Phone                        Fax
            Information
                        Company                                                                 E-mail

                        Street
                        City                                       State                        Zip


            Ship To     Name
            Information
            (if different   Company                                                     Commercial    Residential
            from above)
                        Street

                        City                                       State                        Zip

            Ownership    Individual      Partnership      Corporation    Other, explain ___________________________________

                        Principals

                        Name                                       Address                      City, State, Zip
                        Federal I.D. Number

                        Years in Business

            Customer    1.  PO required?            yes   no          4.  Require fax or email
            Special     2.  Monthly statements?     yes   no             acknowledgments on all orders.   yes   no
            Conditions     If yes, do you want:    Email    Fax    Mail  5.  Print your part # on packing slip?   yes   no
            (circle your      If no, you will only receive invoice. How do you want to   6.  Designate orders to:
            choice)        receive your invoice?   Email    Fax    Mail     a.  ship complete / no back orders
                        3.  Print prices on packing slip?   yes   no     b.  ship complete unless otherwise specified
                           (not recommended for those                    c.  ship partials / ship back orders complete
                           using our drop ship program)                  d.  ship partials / ship back orders as they come in


            Bank        Bank Name                                  Address
            Reference
                        Type of Account        Account #           Bank Officer’s Name          Phone

            Vendor
            Reference   Company                                    Fax

                        Street                                     Phone                        E-Mail
                        City                                       State                        Zip

                        Company                                    Fax
                        Street                                     Phone                        E-Mail

                        City                                       State                        Zip
                        Company                                    Fax

                        Street                                     Phone                        E-Mail
                        City                                       State                        Zip
            NOTE: If applicable, your PA or FL Sales Tax Exemption Certificate form MUST accompany your credit application.
            I the undersigned confirm that all information given in this application is true and correct to the best of my knowledge. I understand that terms on all purchases
            are net 30 days. If this application is approved, I recognize that I/we will be responsible for any attorney’s fees and/or costs incurred in the collection of any
            unpaid balance.

                                           Signature                                                 Date
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