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Submit a Credit Application

To submit an application for credit, please fill out the form below and click submit. Your application will be processed right away.

You may also request information by calling us at (205) 595-8381 or toll free at (800) 245-1183.

Required fields are marked in red.  
Company Name:
Type of Business:
Operating Structure:
How Long In Business:
Name of Parent Company (if subsidiary):
President/Owner First Name:
President/Owner Last Name:
Accounts Payable Contact Name:
Telephone:
Fax:
Email Address:

Billing Address:

  

Shipping Address:

 (if different)
Street Address: Street Address:
Suite: Suite:
City: City:
State: State:
Zipcode: Zipcode:
Additional comments or instructions regarding billing or shipping:

Bank Reference:

      
Bank Name:
Contact Name: Account Reference:
Telephone: Fax:
Address:

Trade Reference 1:

      
Company Name:
Contact Name: Account Reference:
Telephone: Fax:
Address:

Trade Reference 2:

      
Company Name:
Contact Name: Account Reference:
Telephone: Fax:
Address:

Trade Reference 3:

      
Company Name:
Contact Name: Account Reference:
Telephone: Fax:
Address:
I Agree: It is hereby certified that the foremention information is true and correct to the best of my knowledge. If approved, we agree to pay all charges in accordance with the terms stated on invoices. If we fail to do so, we agree to pay any late charges, collection expense, attorney fees or service charges if collection procedures are instituted. This hereby authorizes the firm to whom this application is made to verify information on our company, including requesting reports from any commercial or consumer credit reporting agency.
Signed:
Title:
Date:
 

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