Contact Us - New Accounts!

Name of Firm Amount of Credit Requested: Type of Business: Billing Address: City: State: Zip: Phone #(Including Area code): Fax #(Including Area code): Email Address:

Physical Location: City: State: Zip:

Mailing Address: City: State: Zip:

# of years in business: Owner of Business: If yes, name & address of parent company:

Name of Applicant: Title: Purchasing Agent Maintenance Supervisor Tax Exemption#

Local Credit References
(List at least three commercial accounts active for 6 months)

Please list: Name, Address, and Telephone Number, in that order. Thank you.

Ref #1 Ref #2 Ref #3 Ref #4 Bank References Bank Officer Handling Acct Dun & Bradstreet Rating (Optional)

Please Read Carefully

Our credit terms are net 30. If account is past due, we can legally charge 1 1/2% per month late charge and any collection or attorney fees necessary to collect account. Please indicate your willingness to handle this manner by completing the balance of this statement.

We will contact you when the account is approved. Thank You for choosing STUART HOSE & PIPE.