( )
Name of Firm or Individual Phone Number with Area Code
( )
Address Fax Number with Area Code
City State Zip Year Established
HEREBY applies for credit in accordance with the terms and conditions of: Terms Net 30 unless otherwise stated.
The following information must be provided. It will be held in the strictest confidence.
OWNERSHIP:
q Corporation q Check here if incorporated within the past 12 months q Partnership q Individual
1.
Name(s) of Principal(s) Complete Address Zip Phone #
2.
Name(s) of Principal(s) Complete Address Zip Phone #
OWNERSHIP INFORMATION:
Must provide Federal ID # or Driver's License #
Federal ID # Driver's License #
Description of Business:
* Note: If purchases from Spectrum Janitorial Supply Corporation are sales tax exempt, a certificate must be provided.
FINANCE:
Bank / Institution Account #
( )
Bank Officer or Department Bank Telephone #
BILLING:
_______________________________________________________________________________________
Address
________________________________________ _________________________________________
A/P Name Phone #
____________________________________ ____________________________________
Fax # E-Mail Address
Billing Preference: q Mail q Fax q E-Mail
TRADE REFERENCES:
1. ________
Business Name Complete Address Zip Phone # Fax #
2. ____________________________________________________________________________________________________________
Business Name Complete Address Zip Phone # Fax #
3. ____________________________________________________________________________________________________________
Business Name Complete Address Zip Phone # Fax #
4. ___________________________________________________________________________________________________________
Business Name Complete Address Zip Phone # Fax #
OTHER INFORMATION:
q Yes q No If someone other than company / individual listed above will be paying. (If yes, please list below)
____________________________________________________________________________________________________________
Business Name Complete Address Zip Phone # Fax #
q Check here if cash sales are okay until credit is approved.
We certify that all the information on this form is correct.
We fully understand your credit terms and agree to the proper payment in consideration of extended credit.
q I am a new customer requesting an account.
q I am an existing customer requesting an account. My salesperson is:
Signed
Title Date
When your credit application is approved or rejected, who do we contact and how? (Please print)
_______________________________ _(_____)__________________________
Name Phone #
_(_____)________________________ ________________________________
Fax # E-mail
*** Please Print and Mail to: ***
Spectrum Janitorial Supply
2702 Applegate
Indianapolis, IN 46203
or fax to:
(317) 788-2021
or scan and email to:
info@specjan.com
