EmailMe Form - CUSTOMER CREDIT APPLICATION

Date *

MM / DD / YYYY

Company Name *

Address *

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

County *

Phone *

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

Email *

Dun & Bradstreet #

Federal ID # *

State ID #

Tax Exemption Form

Is your purchase tax exempt? ***If YES, upload a copy of your tax exemption form.

P.O. Numbers *

Yes

No

Do you require Purchase Order Numbers?

Invoice & Statement Delivery *

Email

Mail

What is your preferred method to receive invoices for payment?

Invoice & Statement Information *

Please enter the email or mailing address for invoices and statements to be sent to.

Salesperson

ACCOUNTS PAYABLE INFORMATION

Contact Name *

First Last

Phone *

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

Credit Line Requested *

CREDIT REFERENCES

Credit Reference Name #1 *

First Last

Phone *

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

Email *

Address *

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

Credit Reference Name #2 *

First Last

Phone *

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

Email *

Address *

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

Credit Reference Name #3 *

First Last

Phone *

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

Email *

Address *

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

Please be advised that all purchases are due Net 30 days from date of purchase. A service charge of 1.5% per month will be added to past due balances.

Accept Credit Terms *

I have read and accept the credit terms listed above.

I give permission to EcoShield Asphalt Products to obtain credit information from the above references and/or from a credit bureau.

Name *

First Last

Title *

Signature *

Clear

Date Time *

MM / DD / YYYY