Credit Application

Registered Name of Company:
Billing Address
Address:
City:
State:
Zip Code:
Shipping Address
Address:
City:
State:
Zip:
Telephone:
Fax:
Describe Type of Business:
In Business Since:
Legal Structure of Business: (Choose One)	Corporation Partnership Proprietorship
Federal ID Number:
DUNS Number:
Names of Owner/President, Partners, and/or Corporate Officers
Name:
Title:
Name:
Title:
Name:
Title:
Will the Owner/President, Partners, and/or Corporate Officer be liable for all debts?	Yes No
Accounts Payable Contact:
Please Attach Tax Exemption Certificate (If Applicable)
Requested Credit Line:
Credit and Trade References
Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Bank Reference
Name:
Location:
Account Number:
Telephone:
Contact Name:
Terms of Sale: NET 30 DAYS All past due accounts will be assessed service charges at the rate of 1.5% per month. Past due accounts are subject to suspension of all credit privileges. In the event Tri State Foam retains the services of an attorney to collect any indebtedness owed, you agree to pay reasonable attorney's fees and court cost so incurred by Tri State Foam Products.

(800) 277-0967