EmailMe Form - Coolcentric Domestic Customers

Customer Legal Name *

Doing Business As

Type of Business

Duns No

Phone

### - ### - ####

Billing *

Street Address City State / Province / Region Postal / Zip Code

Shipping Address *

Street Address City State / Province / Region Postal / Zip Code

Federal ID #

Please attach the following documents:
- Tax Exemption Certificate
- W-9

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, Inc. reserves the right to request current financial statements.

Date Time

MM / DD / YYYY

Signature *

Clear

Simon Industries, Inc. 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?