Email Company Information Name of Business: * Salesperson: Billing Address: * City: * State: * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: * Phone: * Type of Business: In Business Since: Shipping Address: City: State: - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone: Accounts Payable Contact: * Phone * Email: * Invoice Email: The email address you would like to receive your electronic invoice. Bank References Institution Name: Address: Phone Trade References Enter reference below or you can upload saved information to the right. Upload Trade References Add File Company Name: Contact Name: Address: Phone: Account Opened Since: Credit Limit: Current Balance: Company Name: Contact Name: Address: Phone: Account Opened Since Credit Limit: Current Balance: Company Name: Contact Name: Address: Phone: Account Opened Since: Credit Limit: Current Balance: Tax Exempt Forms Attach your tax exempt form or fax into us at (336) 714-4755 taxexempt Add File I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein. Signature/Title: * Typing your name above acts as a digital signature Date:
