Credit Application

New Account Information

Company name *

Mailing address *

City *

State *

Zip code *

Shipping address

City

State

Zip

Telephone *

Fax *

Contact person *

Email address

Name of accounts payable representative *

General Information

Type of organization *

Type of business *

Taxable * Yes No Sometimes

Nearest EJP Location *

Key Personnel (required)

Person #1

Owners, partners, or officer name *

Title *

Residence address *

Home phone *

Name and location of any other businesses owned *

Person #2

Owners, partners, or officer name *

Title *

Residence address *

Home phone *

Name and location of any other businesses owned *

Trade Reference (required)

Reference #1

Company *

Address *

City *

State *

Zip code *

Telephone *

Fax *

Contact person *

Email address

Reference #2

Company *

Address *

City *

State *

Zip code *

Telephone *

Fax *

Contact person *

Email address

Reference #3

Company *

Address *

City *

State *

Zip code *

Telephone *

Fax *

Contact person *

Email address

Bank Information

Company *

Address *

City *

State *

Zip code *

Telephone *

Fax

Contact person *

Email address

Acknowledgement

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.