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United Electric Supply
Credit Application

What Location Are You Requesting Credit
For ?
Company Name
Billing Address
City
State
Zip Code
Shipping Address
City
State
Zip Code
Nature of Business
Telephone
No. Years in Business
Type of Business..

Full Name of Officers of Corporation and Titles (Please list full names and addresses of owners and individual or partners).

Name
Title
Address
Phone No.
City
State
Zip Code
Social Security No.

Officers of Corporation and Titles # 2

Name
Title
Address
Phone No.
City
State
Zip Code
Social Security No.
Officers of Corporation and Titles # 3
Name
Title
Address
Phone No.
City
State
Zip Code
Social Security No.
Are Purchase Orders Required
Sales Tax Status
What is the Tax Exemption
Number
License Number
(For Contractors)
Principle Bonding Co.
(For Contractors)
Address
City
State
Zip Code
Sr. Purchasing Agent
Phone No.

TRADE REFERENCES
(Please include complete mailing address and Phone number)

Name
Address
City
State
Zip Code
Phone No.

TRADE REFERENCES # 2

Name
Address
City
State
Zip Code
Phone No.

TRADE REFERENCES # 3

Name
Address
City
State
Zip Code
Phone No.

TRADE REFERENCES # 4

Name
Address
City
State
Zip Code
Phone No.

BANK INFORMATION

Principle Bank
Address
City
State
Zip Code
Account Number
Bank Officer in Charge
of Account

Payment Terms:

Service Charge up to 2% will be assessed on overdue balances. Accounts exceeding
30 day period will be subject to restricted credit. Payment records dictate the
acceptable limits of credit. Unauthorized deductions or discounts will be considered
overdue and billed back on account.
Annual Sales Volume $
Credit Limit Requested $
Estimated Monthly Purchase $
Special Billing Requirements
As evidenced by submitting this form the information in this application is true and factual and provided to United Electric for the purpose of the extension of credit. Permission is granted to contact references or any other source to obtain credit information. We agree to make payments in accordance with invoice terms and to pay monthly service charges when added on overdue balances. The undersigned warrants that the individual executing this application is authorized to do so and to bind the applicant to the liabilities and obligations set forth.
Company Name
Date
Applicants Name
Applicants Title

All Right Reserved United Electric Supply Inc.