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City:
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Shipping Address:
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Contact Person:
Email Address:
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Type of organization: Corp Partnership Proprietor Other
Type of business: City Contractor Engineer Excavator Government Lumber Other Plumber Town Trailer Park Sewer Only Water Co. Water & Sewer Wholesale
Yes: No: Sometimes:
Nearest EJP Location: Bangor, ME Barre, VT Brockton, MA Concord, NH Corfu, NY Fort Wayne, IN Gardiner, ME Geddes, NY Hatfield, MA Hopkinton, MA Indianapolis, IN Jeffersonville, IN Lafayette, IN Keene, NH Lima, OH Lincoln, RI Mashpee, MA MBS Middleton, MA Montpelier, VT Pembroke, NY Portland, ME Putnam Pipe Corporation Round Lake, NY So. Barre, MA So. Burlington, VT Springfield, MA Syracuse, NY Vernon, CT Warwick, RI West Carrollton, OH West Chesterfield, NH
Owners, Partners, or Officer Name:
Title:
Residence Address:
Home Phone:
Name and location of any other businesses owned:
Insurance Agent:
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This section is optional but may help us approve your application.
Agreement: I hereby acknowledge that I have read the agreement and understand same.
Terms and Conditions: I hereby acknowledge that I have read the Terms and Conditions of Sale.
Personal Guaranty (optional): I hereby acknowledge that I have read the personal guaranty and understand same. (PLEASE NOTE: A Personal Guarantee is not required in order to submit a credit application, but it is a factor considered in determining whether to approve or decline an application.)
