Credit Application

Company name *

Mailing address *

City *

State * --------- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip code *

Same address for shipping?

Shipping address

City

State --------- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip

Telephone *

Fax *

Contact person *

Email address *

Name of accounts payable representative *

Type of organization * --------- City Contractor Engineer Excavator Government Lumber Plumber Town Trailer Park Sewer Only Water Co. Water & Sewer Wholesale Other

Type of business * --------- Corp Partnership Proprietor Other

Taxable *      Yes      No      Sometimes

Nearest EJP Location * --------- Vernon, CT Fort Wayne, IN Indianapolis, IN Jeffersonville, IN Lafayette, IN Brockton, MA Mashpee, MA Middleton, MA Pittsfield, MA Shrewsbury - Shrewsbury, MA Quality Water Products - So. Barre, MA Springfield, MA Whately, MA Bangor, ME Home Office - Gardiner, ME Maine Division - Gardiner, ME PEP Transportation - Gardiner, ME PPF -Plastic Pipe Fabrication a division of EJP - Gardiner, ME Portland, ME Concord, NH Meter and Backflow Services - Concord, NH Keene - W. Chesterfield, NH Blasdell, NY Round Lake, NY Syracuse, NY Lima, OH West Carrollton, OH Lincoln, RI Montpelier - Barre, VT South Burlington, VT