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.

Billing Information.


Company Name *


PO Box


Street Name *


City


State


Five digit zip code, dash (-), four digit postal code. *


Phone Number *


Fax Number


E-mail Address


URL


Is your billing information the same as your shipping information?

If Not Please enter your Shipping Information below.


Company name.


PO Box.


Street Name.


City.


State.


Five digit zip code, dash (-) and four digit postal code

OWNERSHIP


Type of Ownership


Are you listed in Dun & Bradstreet?	YesNo


Dun & Bradstreet Account # -


Owner's Name *


Bookkeeper


Owner's S.S.# *


Years in Business

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 Fax


Reference 2 Phone *

PREFERENCES


Desired Credit Line $ *


PO Required?	YesNo


How would you like your invoices sent?


Do you have CFC certification?

If so, please fill out the CFC form under the New Customer tab on the main website.


Please list people authorized to charge to this account.


Comments:

Last revised: September 14, 2006