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BASIC ACCOUNT INFORMATION
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Full Business Name, (Account Name)
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Primary Contact Name
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Billing Address Information
City:
State:
Zip:
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Shipping Address Information
City:
State:
Zip:
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Billing Contact Information
Name:
Phone Number:
Fax Number:
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Shipping Contact Information
Name:
Phone Number:
Fax Number:
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e-mail address
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Please enter the e-mail address to which all "online account
information" should be sent.
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Web address (URL)
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Please enter the internet web address or URL, if any. |
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ORGANIZATIONAL INFORMATION
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Yrs. In Bus.:
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Please indicate the type of organization and how long it has been in
operation.
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Resale #
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Please enter your business Resale number. A resale number is required, and
in order for us to comply with the State of Ohio Sales and Use Tax Laws we are required to
have a signed Sales/Use Tax Exemption Certificate on file. Click here
to download a copy of your State's Sales Tax Exemption Certificate and complete and fax a copy
to 1-419-483-8326.
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Enter your Company DUNS #:
or
Corporate head office phone number:
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If you know your company's "DUNS #", enter it in the space provided.
If you don't know or don't have a DUNS #, put in the main phone number to your
corporate head office.
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CREDIT REFERENCE INFORMATION
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For the banking institution and each of the business institutions identified below, please
provide the name and principal address of your applicable reference.
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For the banking institution and each of the business institutions identified below, please
provide the name, and telephone and fax numbers for your primary contact at each applicable
reference.
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Banking Reference Information
City:
State:
Zip:
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Banking Contact Information
Name:
Phone Number:
Fax Number:
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Business Reference #1 Information
City:
State:
Zip:
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Business Reference #1 Contact Information
Name:
Phone Number:
Fax Number:
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Business Reference #2 Information
City:
State:
Zip:
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Business Reference #2 Contact Information
Name:
Phone Number:
Fax Number:
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| Desired Credit Line $
Require PO:
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Please indicate the amount of credit you are requesting and whether you require the use
of a purchase order.
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Applicant's Authorization Agreement
By submitting this application, Midstate Plastics Corporation
is hereby authorized to obtain credit and/or financial information from
my/our bank(s) or other financial institutions or commercial firms with whom I/we have
done business. It is understood that any such credit and/or financial information will
be held in strict confidence and used only in consideration of this application.
Upon approval of this application, it is agreed that all purchases will be paid in
full and in accordance with the terms of sale as stated on
invoices(s). Should I/we not pay Midstate Plastics or any of its affiliates
according to terms, it is understood that credit priveledges may be withdrawn. If
it is necessary to obtain assistance in the collection of any past due balances, I/we
agree to pay reasonable attorney fees, collection fees, and/or court costs allowable by
law. A copy of this statement and application has been received.
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