Credit Application | Fernco

New Customers

Contact Information

Company Name: *

Your Name: *

Phone #: *

Fax #:

Email: *

Business Info

How long in business: *

Type of Business: *

Purchasing Agent's Name: *

D&B #: *

Bank Name: *

Bank Phone #: *

Billing Information

Address: *

City: *

State: *

Zip: *

Shipping Information

(If different from Billing Information)

Address:

City:

State:

Zip:

Credit References

(Please fill out 3 credit references below)

Reference Info

Name: *

Phone #: *

Fax #: *

Selling Terms: *

High Credit: *

How Long Sold: *

Date of Last Sale: *

Reference Info

Name: *

Phone #: *

Fax #: *

Selling Terms: *

High Credit: *

How Long Sold: *

Date of Last Sale: *

Reference Info

Name: *

Phone #: *

Fax #: *

Selling Terms: *

High Credit: *

How Long Sold: *

Date of Last Sale: *

Create Account Request Submitted By

Your name: *

Title: *

Agency: *

Phone: *