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Dealers Application Form
Date
Buyer Identification
"Buyer" includes all subsidiaries, division and affiliates
First Name
Last Name
Trade name (if different)
Business Address
Federal EIN/Social Security No.
State Resale Cert. #
Business Type
Corp
LLC
Individual
Partnership
Other
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Contact Names
Office Phone
Cell Phone
Fax
Dates Business Formed
Email
History
State Business Formed
Have you done business under any other name in the past 5 years?
Yes
No
With us?
Yes
No
Have you or any company with which you were associated in the past 5 years been subject to any bankruptcy or insolvency proceeding?
Yes
No
Are there any judgments or legal proceedings pending or threatened respecting Buyer or any Guarantor?
Yes
No
Company Principals-Owners
(All must be set forth below)
1.
Name
Title
Soc. Sec. No.
Drivers Lic. No
Home Address
Home Phone
2.
Name
Title
Soc. Sec. No.
Drivers Lic. No
Home Address
Home Phone
3.
Name
Title
Soc. Sec. No.
Drivers Lic. No
Home Address
Home Phone
Bank References
1.
Name
Address
Account #
Contact Name
Phone
Email
2.
Name
Address
Account #
Contact Name
Phone
Email
Trade References
1.
Name
Address
Account #
Contact Name
Phone
Email
2.
Name
Address
Account #
Contact Name
Phone
Email
3.
Name
Address
Account #
Contact Name
Phone
Email
Initial Project
Address
Tax Lot
Tax Block
Owners
Buyers Contract at Initial Project is with
Owner
General Contractor
Subcontractor
Tenant
Project Manager
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Type
Residential
Commercial
Industrial
Governmental
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ALL SUBSEQUENT PROJECTS MUST BE SIMILARLY DESCRIBED FOR GOODS TO BE SHIPPED
Purchase Order Required
Yes
No
Requested Credit Line
This will not limit liability for greater amounts.
CREDIT INFORMATION:
Buyer and Guarantor(s) authorize (1) Seller to contact or to have others contact references and to obtain credit reports and make other credit inquiries about Buyer and Guarantor(s) now and in the future to update information so long as Buyer's obligations are outstanding and (2) such other sources chosen by Seller to provide similar information.
CREDIT CARD AUTHORIZATION:
Buyer and the undersigned hereby authorizes Seller to charge purchase of Buyer to the following credit card account:
Name on Account
Address of Cardholder
Name of Credit Card Issuer
Account Number
Security Code
Expiration Date
BUYER AGREES TO ALL OF THE TERMS AND CONDITIONS OF THIS DOCUMENT INCLUDING THOSE THAT FOLLOW THIS SIGNATURE ON THE NEXT PAGE
Dated
Witness
Buyer E-Signature
Title
I accept terms & conditions
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