Customer Credit Application

Company Name

Contact Name

Website

Phone

Fax

Address

Street Address Address Line 2 City State ZIP Code

A/P Contact

Contact Name

Email

Phone

Can We Email Invoices To You?

Yes
No

Purchasing Contact

Contact Name

Email

Phone

Fax

PO Required

Yes
No

Maintenance Contact

Contact Name

Email

Fax

Phone

Equipment Information

Equipment Location/Ship-To Address

Street Address Address Line 2 City State ZIP Code

Business Information

Owner/President

Type

Corporation
Partnership
Individual

Nature Of Business

Date Started

MM

DD

YYYY

FEIN

SIC Code

Do you pay sales tax?

Yes
No

Sales Tax Exempt Number

If 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 Form

Please upload your sales tax exempt form here

Trade References

Company Name*

Contact Name*

Phone*

Fax

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Company Name

Contact Name*

Phone*

Fax

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Company Name

Contact Name

Phone

Fax

Email

Address

Street Address Address Line 2 City State ZIP Code

Banking Reference

Bank Name

Account Number*

Contact Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

* Make all checks payable to: Delta Industries, Inc., and remit to 2201 Curtiss Street, 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.

Name

Date

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.

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