EmailMe Form - Simon Industries International Customers

Customer Legal Name *

Doing Business As

Type of Business

Duns No

Phone - International Customers

Billing *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Shipping Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please complete the attached certificate of end of use

End Of Use Form

Buyer Contact

Email Address

Phone

A/P Contact *

Email Address *

Phone

EITHER ATTACH COMPANY TRADE REFERENCE DOCUMENT OR COMPLETE THE FOLLOWING TRADE REFERENCE FIELDS

*

Yes

Please select one of the two options provided and click Yes upon completion

Add Trade Reference Document

Trade References
Company

City,State

Phone

Email

Trade References
Company

City,State

Phone

Email

Trade References
Company

City,State

Phone

Email

Anticipated credit requirement *

$ Dollars

Anticipated Initial PO Requirement *

$ Dollars

Simon Industries reserves the right to request current financial statements.

Date Time

MM / DD / YYYY

Signature *

Clear

Simon Industries is authorized to check Applicant’s credit and bank references and credit history and to answer questions posed to it by
others about Applicant’s credit experience with Wakefield Thermal Solutions, Inc and its subsidiaries.
TERMS AND CONDITIONS (see below)
Person signing this application on behalf of Applicant, personally represents and warrants that he/she has full authority to do so.

Printed Name *

First Last

Title: *

Phone

Agree to the Terms and Conditions? *

Yes

Click above if you have read and agree to the Terms and Conditions

Have you uploaded all requested documents?