Credit Application

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Step 1: Resell/Exemption Certificate

In order for us to comply with the State of Kansas Sales and Use Tax Laws, we are required to have a signed Resell/Use Certificate on file.

Step 2: Credit Application

Please provide the following credit information.

Step 3: Submission of Application

By submitting this application you certify that you have the authority to submit this information and request credit for this company. If approved, the Standard Terms are NET10th. Accounts with a past due balance will be charged a service charge of 1.5% (18% Annum) on the past due amount. You agree to pay all invoices within the terms specified.


Company Name *


PO Box


Street Name *


City


State


Zip *


Phone Number *


Fax Number


E-mail Address


URL

OWNERSHIP


Type of Ownership


Are you listed in Dun & Bradstreet?	YesNo


Dun & Bradstreet Account # -


Owner's Name *


Owner's S.S.# *

REFERENCE INFORMATION

BANK Reference


Bank Name *


Bank Officer *


Bank Address *


Bank City *


Bank State


Bank Zip *


Bank Phone *


Bank Fax

BUSINESS Reference


Reference Name *


Reference Address *


Reference City *


Reference State


Reference Zip *


Reference Phone *


Reference Fax

BUSINESS Reference 2


Reference 2 Name *


Reference 2 Address *


Reference 2 City *


Reference 2 State


Reference 2 Zip *


Reference 2 Phone *


Reference 2 Fax

PREFERENCES


Desired Credit Line $ *


PO Required?	YesNo


Comments:

Last revised: September 14, 2006