Credit Application

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.

Please enter your Name. Company Name *

PO Box

Please enter a Street Name Street Name *

City

State

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

Please fill in all required fields. 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

Please select an option from the group. Are you listed in Dun & Bradstreet? *
Yes No

Dun & Bradstreet Account # -

Please fill in all required fields. Owner's Name *

Bookkeeper

Years in Business

REFERENCE INFORMATION

BANK Reference

Please fill in all required fields. Bank Name *

Please fill in all required fields. Bank Officer *

Please fill in all required fields. Bank Address *

Please fill in all required fields. Bank City *

Bank State

Please fill in all required fields. Bank Zip *

Please fill in all required fields. Bank Phone *

Bank Fax

BUSINESS Reference

Please fill in all required fields. Reference Name *

Please fill in all required fields. Reference Address *

Please fill in all required fields. Reference City *

Reference State

Please fill in all required fields. Reference Zip *

Please fill in all required fields. Reference Phone *

Reference Fax

BUSINESS Reference 2

Please fill in all required fields. Reference 2 Name *

Please fill in all required fields. Reference 2 Address *

Please fill in all required fields. Reference 2 City *

Reference 2 State

Please fill in all required fields. Reference 2 Zip *

Reference 2 Fax

Please fill in all required fields. Reference 2 Phone *

PREFERENCES

Please fill in all required fields. Desired Credit Line $ *

Please select an option from the group. PO Required? *
Yes No

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:

Are you Tax Exempt?
Yes No

If you answered Yes to Tax Exempt, please fill out the Tax Form under the New Customer Tab on the Main Website

Would you like to be set up with Online Shopper?
Yes No Already have One

If you answered Yes to Online Shopper, please fill out an ID/Password no more than 8 Characters long.

Online Shopper Login

Online Shopper Password

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Last revised: September 14, 2006