All sections of forms must be completed in their entirety and returned to the Credit Department before consideration will be given to any request. This application is for the confidential use of the Credit Department.

Billing Information

Company Name *

Address *

City *

State *

Zip Code *

Country *

Phone Number *

Fax

Email Address *

Preferred Method of Receiving Invoices/Statements *

Shipping Information

First Name *

Last Name *

Email Address *

Address *

City *

State *

Zip Code *

Business Information

Type of Business *

Business Started Date *

Business Type *

Federal Tax ID *

Corporate Officers

President *

Vice President *

Secretary/Treasurer/CFO *

Owners or Partners *

Purchasing Agent/Buyer Details

Purchasing Agent/Buyer *

Phone *

Fax

Email *

Accounts Payable Account Details

Accounts Payable Account *

Phone *

Fax

Email *

Credit References

Please list three credit references with whom you have open account. If new in business with no established credit references, please list four personal references other than family.

Reference 1

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax

Reference 2

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax

Reference 3

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax

2430 Mountain Industrial Boulevard
Tucker, GA 30084
Tel: 770-270-1010
Cell: 770-905-0909