Service Center Registration App

Company Information Legal Name * Email * Phone Number * Billing Address *

City *

County/State *

Zip/Postal Code *

Use as Shipping Address

Shipping Address *

City *

County/State *

Zip/Postal Code *

Company Web Address

Business Facts Proprietorship

Type of Business

Years in Business *

Industry *

Buying Group

Date Joining Buying Group

Buying Group Info Tax Exempt Number * Currency * Resale Certificate No * Please attach your Resale Certificate *

Corporate Information Corporate Name * Corporate Title *

Corporate Name 2 Corporate Title 2 Corporate Name 3 Corporate Title 3

Controller and A/P Info Controller * A/P Contact * A/P Phone * A/P Email *

Purchasing Info Purchasing Agent Contact * Purchasing Agent Email * Purchasing Agent Phone

Reference Info

Three required for submission

Reference Company Name * Reference Contact * Reference Address * Reference Email * Reference Phone *

Second Reference

Second Reference Company Name * Reference Contact * Reference Address * Reference Email * Reference Phone *

Third Reference

Third Reference Company Name * Reference Company Contact * Refrerence Address * Reference Email * Reference Phone *

Signed By (Initials) *

The undersigned agrees that the information supplied on this Credit Application is true and correct and authorizes their bank and
references to release information as desired by the seller’s usual credit investigation

The undersigned has reviewed the Standard Terms and Conditions and agrees to adhere to all policies outlined.

Company Information Legal Name * Email * Phone Number * Billing Address *

City *

County/State *

Zip/Postal Code *

Use as Shipping Address

Shipping Address *

City *

County/State *

Zip/Postal Code *

Company Web Address

Business Facts Proprietorship

Type of Business

Years in Business *

Industry *

Buying Group

Date Joining Buying Group

Buying Group Info Tax Exempt Number * Currency * Resale Certificate No * Please attach your Resale Certificate *

Corporate Information Corporate Name * Corporate Title *

Corporate Name 2 Corporate Title 2 Corporate Name 3 Corporate Title 3

Controller and A/P Info Controller * A/P Contact * A/P Phone * A/P Email *

Purchasing Info Purchasing Agent Contact * Purchasing Agent Email * Purchasing Agent Phone

Reference Info

Three required for submission

Reference Company Name * Reference Contact * Reference Address * Reference Email * Reference Phone *

Second Reference

Second Reference Company Name * Reference Contact * Reference Address * Reference Email * Reference Phone *

Third Reference

Third Reference Company Name * Reference Company Contact * Refrerence Address * Reference Email * Reference Phone *

Signed By (Initials) *

The undersigned agrees that the information supplied on this Credit Application is true and correct and authorizes their bank and
references to release information as desired by the seller’s usual credit investigation

The undersigned has reviewed the Standard Terms and Conditions and agrees to adhere to all policies outlined.