Customer Credit Application

Company

Company Name *

Company Phone *

Company Website *

Owner/Managing Partner

Owner's First Name

Owner's Last Name

Owner's Phone

Owner's Email

Physical Address

Physical Address *

Physical City *

Physical State *

Physical Postal Code *

Billing Address

Billing Address *

Billing City *

Billing State *

Billing Postal Code *

Contractor's License

Contractor's License *

Seller's Permit

Seller's Permit Upload *

Resale Certificate

Resale Certificate Upload *

Accounting Contact

Accounting Contact First Name

Accounting Contact Last Name

Accounting Contact Title *

Accounting Contact Phone *

Accounting Contact Email *

Additional Contact 1

Additional Contact 1 First Name

Additional Contact 1 Last Name

Additional Contact 1 Title

Additional Contact 1 Phone

Additional Contact 1 Email

Additional Contact 2

Additional Contact 2 First Name

Additional Contact 2 Last Name

Additional Contact 2 Title

Additional Contact 2 Phone

Additional Contact 2 Email

Additional Contact 3

Additional Contact 3 First Name

Additional Contact 3 Last Name

Additional Contact 3 Title

Additional Contact 3 Phone

Additional Contact 3 Email

Bank Reference

Bank Name *

Bank Phone

Checking *

Routing *

Bank Address *

Bank City *

Bank State *

Bank Zip *

Payment Terms Requested *

Attachment

Trade Reference 1

Trade Reference 1 Company

Trade Reference 1 Contact

Trade Reference 1 Phone

Trade Reference 1 Email

Trade Reference 2

Trade Reference 2 Company

Trade Reference 2 Contact

Trade Reference 2 Phone

Trade Reference 2 Email

Trade Reference 3

Trade Reference 3 Company

Trade Reference 3 Contact

Trade Reference 3 Phone

Trade Reference 3 Email

Trade Reference 4

Trade Reference 4 Company

Trade Reference 4 Contact

Trade Reference 4 Phone

Trade Reference 4 Email

Completed By

Signer's Email *

Signer's First Name

Signer's Last Name

Signer's Title *

Signature *

Clear

Disclosure *

I hereby certify that the information contained herein is complete and accurate, and the person executing this agreement has authority to bind the customer and is authorized by the customer to enter into the credit application terms and conditions. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein. The undersigned hereby acknowledges and agrees to all the terms and conditions of this Credit application and to the terms and conditions set forth on the reverse of this Application. The undersigned understands that Rack Store LLC must be notified in writing by certified mail of any change in ownership, the name or business structure under which credit is established. The federal equal credit opportunity act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national original, sex, marital status, age, (provided the applicant has the capacity to enter into a binding contract), because all or part of the applicants income derives from any public assistance program, or because the applicant has in good faith exercised any right under the consumer credit protection act to the extent is would apply. Resale certificate or tax exempt form must accompany this application to complete the processing.