251 Union Street Westfield, MA 01085
1-800-
628-9034
Credit Application
*First Name
*Last Name
*Company
*Billing Address
*City
*State
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*Zip
Country
*Phone
Fax
*Email
Shipping Address
City
State
INTL
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
Country
Credit Information:
Estimate of credit requested:
Type of business:
D & B Rating
Tax ID or SS#:
Years in Business:
Credit References:
Bank Reference Name:
Account #:
Phone:
Contact:
Trade Reference Name:
Account #:
Phone:
Contact:
Trade Reference 2 Name:
Account #:
Phone:
Contact:
Trade Reference 3 Name:
Account #:
Phone:
Contact:
Is applicant subject to sales tax?
Tax Exemption Number:
Please advise if Parent, Division, Branch or Subsidiary:
This section to be completed by Proprietorship or Partnerships.
Name of owner or authorized persons who will be responsible for payment of account. (Minimum of two references.)
Name:
Address:
Phone:
SS#:
Bank (Personal):
Position or Title:
Name:
Address:
Phone:
SS#:
Bank (Personal):
Position or Title:
By submitting this form the applicant acknowledges that should credit be approved, the terms are net 30, from the date of invoice. Invoices not paid within these terms may be subject to a service charge.
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