1373 Boggs Drive PHONE: (336) 719-9000 Mount Airy, NC 27030 FAX: (336) 719-9097 CREDIT APPLICATION Updated 1/08/13 BILL TO: SHIP TO: Legal Name of Credit Applicant: DBA Trade Name(s): Mailing/Street Address: City/State/Zip: County: Telephone Number: Fax Number Website Address ( If Available) TYPE OF ORGANIZATION Business Description: Proprietorship Corporation Date Business Started: Partnership LLC Subsidiary/ Division of Government Other Duns Number Contacts Name Email Address (if available) Telephone Number Financial Officer Accounts Payable Purchasing P.O. Required: Yes No Building/Facility: Owned Leased TRADE REFERENCES Company Name Contact Account # Telephone # Fax # BANK REFERENCE Bank Name Contact Account # Telephone # Fax # Insteel use only Inside Sales Rep Sales Territory: Product: Product Resalable Y N New Customer Y N Date Received: Date Approved: Credit Limit Approved By: Credit Limit Requested Credit Applicant (Please Print) Authorized Signature Title Date Please include the following attachments with the Credit Application: Current Financial Statement (if available) Uniform Sales Tax Certificate (Required)
BILL TO: SHIP TO: Legal Name of Credit Applicant: DBA Trade Name(s): Mailing/Street Address: City/State/Zip: County: Telephone Number: Fax Number Website Address ( If Available)
TYPE OF ORGANIZATION Business Description: Proprietorship Corporation Date Business Started:
Partnership LLC Subsidiary/ Division of Government Other Duns Number Contacts Name Email Address (if available) Telephone Number Financial Officer Accounts Payable Purchasing P.O. Required: Yes No Building/Facility: Owned Leased
TRADE REFERENCES Company Name Contact Account # Telephone # Fax #
BANK REFERENCE Bank Name Contact Account # Telephone # Fax #
Insteel Wire Products use only Inside Sales Rep Sales Territory: Product: Product Resalable Y N New Customer Y N Date Received: Date Approved: Credit Limit Approved By: Credit Limit Requested
Credit Applicant (Please Print) Authorized Signature Title Date
Please include the following attachments with the Credit Application: Current Financial Statement (if available) Uniform Sales Tax Certificate (Required)
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Send completed Credit Application to: E-mail: [email protected] or Fax: (336) 719-9097
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Phone: (336) 719-9000 Option 4
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AUTHORIZATION TO RELEASE INFORMATION – Applicant certifies that all information provided by Applicant herein is true and correct, and agrees that all such information may be used for credit evaluation purposes by Insteel Wire Products Company. I/we hereby authorize all trade and bank references listed in this Credit Application to release all information, verbal or written, to assist Insteel Wire Products Company in determining the amount and conditions of credit to be extended to the applicant.
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ADDITIONAL TERMS AND CONDITIONS – I/we agree and understand that all accounts are due and payable according to the terms stated on the invoice. I/we acknowledge that all credit terms are subject to periodic review, and may be modified at the discretion of Insteel Wire Products Company. I/we agree that in the event credit extended pursuant to this Credit Application is not repaid in accordance with the aforementioned repayment terms, the applicant will reimburse Insteel Wire Products Company for all collection costs incurred, including reasonable attorney fees and court costs. In the event of any changes in ownership or legal structure of the applicant, I/we agree to notify Insteel Wire Products Company in writing of these changes. I/we acknowledge having read and understood the preceding terms and conditions, and certify that the applicant agrees to abide by them.
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