Business Contact Information

Your Company Name*

Your Name*

Your Title*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone Number*

Your Email Address*

Your Fax Number*

Your Company Website Address

Contact and Tax Information

Accounts Payable Contact Name*

AP Email*

Phone*

Fax

Would you like the invoices emailed?*

Yes
No

Invoicing Email

Are you tax exempt?*

Yes
No

Federal Tax #

State Tax #

We must have a copy of your sales tax exempt certificate(s) on record or you will be considered taxable. Please attach the files at the bottom of this form.

Do you have a Freight Collect Account?*

Yes
No

UPS #:

FEDEX #:

Other #:

OTHER? Please also indicate which freight company you use, along with the #

We Require at Least Three Current Trade References to Open an Account.

Reference 1

Reference 1 Company Name*

Reference 1 Contact Name*

Reference 1 Email*

Reference 1 Phone*

Reference 1 Fax Number*

Reference 2

Reference 2 Company Name*

Reference 2 Contact Name*

Reference 2 Email*

Reference 2 Phone Number*

Reference 2 Fax Number*

Reference 3

Reference 3 Company Name*

Reference 3 Contact Name*

Reference 3 Email*

Reference 3 Phone Number*

Reference 3 Fax Number*

Please Attach a Tax-Exempt Certificate if You are Tax-Exempt

Drop files here or

Max. file size: 16 MB.

Agreement

1. Terms granted are NET30, unless otherwise approved. All invoices are to be paid 30 DAYS from the date of the invoice. 2. By submitting this application, you authorize ELECTRONIC FASTENERS, INC. to make inquiries into business/trade references that you have supplied.

Security Verification

Credit Application