Commercial Credit Application

To avoid any delay in processing complete in full.
All information will be held in confidence.

Terms of Credit:
First order is check OR charge card. Our terms are NET 20 days. We ship invoice to invoice.

ALL FIELDS REQUIRED FOR SUBMISSION

BILL TO:SHIP TO:
Name:Name:
Attn:Attn:
Address:Address:
City:City:
State:Zip: State:Zip:
Email: Email:
Phone:Phone:
GENERAL BUSINESS INFORMATION
Business Name :Are you Sales and/or Use Tax Exempt?
Address:D.B.A.
Phone:  
Type of Business:Accounts Payable Contact:
Years in Business:Name
Fed ID#:Phone with ext.
Owner's Name: 
Officer's Name:

 
Title:  
BANK REFERENCE
Bank Name:Account Manager:
City:Phone:
State:Zip:Checking Acct #:
Email:Savings Acct #:
  Other:
BUSINESS CREDIT REFERENCE (LIST MINIMUM OF THREE)
REFRENCE 1:REFRENCE 2:
NameName:
Address: Address:
City: City:
State:Zip:State:Zip:
Email:Email:
Phone:Phone:
REFRENCE 3:REFRENCE 4:
NameName:
Address:Address:
City: City:
State:Zip: State:Zip:
Email:Email:
Phone:Phone:
APPLICATION FILLED OUT BY
Name:Title:
Email Address:  

By submitting this application you authorize Chipurnoi Inc. to make enquiries to the banking, savings, business, and/or trade references you have supplied.

We certify that all the information on this form is correct and that we fully understand your credit terms and agree to the proper payment in consideration of extended credit.

Notes or Message: