Customer Credit ApplicationMicheal Ferris2017-11-15T21:43:04-06:00 Customer Credit Application Customer Credit Application If you are a new customer, please fill out the following form. Company NameContact NameWebsiteWebsite PhoneFaxAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code A/P ContactContact NameEmail PhonePhoneCan We Email Invoices To You? Yes No Purchasing ContactContact NameEmail PhoneFaxPO Required Yes No Maintenance ContactContact NameEmail FaxPhoneEquipment InformationEquipment Location/Ship-To Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business InformationOwner/PresidentType Corporation Partnership Individual Nature Of BusinessDate Started MM DD YYYY FEINSIC CodeDo you pay sales tax? Yes No Sales Tax Exempt NumberIf your business is sales tax exempt you must submit the appropriate States sales tax exempt certificate. State sales tax exempt certificate are available upon request. Please provide your exempt number below:Sales Tax Exempt FormPlease upload your sales tax exempt form hereTrade ReferencesCompany NameContact NamePhoneFaxEmail Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company NameContact NamePhoneFaxEmail Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company NameContact NamePhoneFaxEmail Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Banking ReferenceBank NameAccount NumberContact NamePhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code * Make all checks payable to: Delta Industries, Inc., and remit to 5235 Katrine Ave, Downers Grove Il 60515. * DELTA INDUSTRIES, INC. - TERMS AND CONDITIONS Risk of loss or damage shall pass by Delta Industries, Inc. to Purchaser, and delivery shall be deemed to be complete, upon delivery by Delta Industries, Inc. to a private or common carrier, or upon moving into storage, whichever occurs first. Notwithstanding the foregoing provision, the equipment sold shall remain the property of Delta Industries, Inc. and remain personal property, regardless of mode of attachment to realty or other property, until full payment has been made therefore. Purchaser agrees to execute any security agreements and financing statements or other commercially acceptable document and to perform all acts which may be necessary to perfect and assure retention of title to such equipment by Delta Industries, Inc.. Purchaser agrees upon request to do all things and acts necessary to adequately insure the equipment against loss or damage, and naming Delta Industries, Inc. an additional insured. Neither party may assign or transfer contracts without the prior written consent of the other. Payments for goods and services are due upon receipt of service and/or delivery of goods, and payable within 30 days, or as negotiated on individual contract bases, from the date invoiced. All sales will be COD until your account status has been established. By submitting, the named individual accepts our terms and conditions and attests to his/her authority to do so.NameDate Date Format: MM slash DD slash YYYY Pressing the Submit button will send a copy of this form to our Accounting Department. You should print a copy for your own records before closing this page.
