EmailMe Form - Application for Credit

Company Name *

Company Website *

Billing Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Shipping Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Federal Tax ID# *

State Tax ID# *

Phone # *

Fax #

Email Address *

Organization Information:

Choose One *

Publicly Owned Corp.

Private Corp.

S-Corp.

State of Inc. *

Date of Inc *

MM / DD / YYYY

D & B # *

Choose One *

Partnership

LTD Partnership

Individual Proprietorship

State of Registration *

Date of Registration *

MM / DD / YYYY

Is this business or location a branch, division, subsidiary or owned by another company or organization? *

Yes

No

If yes, please indicate the parent company

Will your purchases be taxable? *

Yes

No

If yes, tax percent?

If no, reason?

If yes, please submit the appropriate tax exemption certificate. Without the appropriate exemption form on file, we are required to charge sales tax.

Submit proof od tax exemption

Full Names and Addresses of all Principals (Officers, Partners, Owners, etc)

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Principal Trade Referances: Full Name, Addresses, Phone and Account Numbers

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Account Number

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Account Number

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Account Number

Please attach any financial documentation that you feel would be helpful to the credit manager in setting a credit line for your account

Additional Documentation

Purchasing Information

Are purchase numbers required on your orders? *

Yes

No

Name of person(s) authorized to make purchases

Prefix First Last Suffix

Additional purchaser

Prefix First Last Suffix

Additional purchaser

Prefix First Last Suffix

Additional purchaser

Prefix First Last Suffix

Main Contact Name *

Prefix First Last Suffix

Main Contact Phone *

### - ### - ####

Main Contact Email *

Accounts Receivable Contact Name *

Prefix First Last Suffix

Accounts Receivable Contact Phone *

### - ### - ####

Accounts Receivable Contact Email *

Would you like your purchases paid for with a credit card? *

Yes

No

If, yes, card type

Card Number

Expiration Date

MM / DD / YYYY

Security Code (back of card)

Is the billing address for th ecredit card the same as above?

Yes

No

If no, please provide the billing address for the card

Street Address City State / Province / Region Postal / Zip Code Country / Region

Terms of Sale

Net 30 days, unless specified above. A finance charge of 1.5% per month will be charged on all invoices over 30 days past due. All shippments are FOB Minneapolis, MN or San Antonio, TX unless otherwise agreed upon.

I agree to pay promptly for all purchases made within our terms of sale. I personally agree to pay costs for collection incurred by DF Countryman Company and all amounts due should we become delinquent or insolvent.

By completing the following signature fields and submitting this form, this acts the same as a "physically" signed document.

Signature of officer *

Prefix First Last Suffix

Title *

Date *

MM / DD / YYYY