Applicant Name*

Date*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Person to Contact (for billing)*

Person to Contact (for shipping)*

Phone (for billing)*

Phone (for shipping)*

Preferred method of invoice receipt*

USPS
Email

Invoice Email*

Expected Monthly Purchases*

See #3 under the Terms below.

Corporation?*

Yes
No

Partnership?*

Yes
No

How long have you been in business?*

Vendor or Federal ID No.*

Will purchase be tax exempt?*

(If yes, return with tax exemption certificate.)

Yes
No

Upload tax exemption certificate*

Max. file size: 50 MB.

Are purchase orders required?*

Yes
No

Trade References: Three required (other than bank or credit cards).

Reference #1

Name*

First Last

Company*

Account Number*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Reference #2

Name*

First Last

Company*

Account Number*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Reference #3

Name*

First Last

Company*

Account Number*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Reference #4

Name

First Last

Company

Account Number

Address

Street Address Address Line 2 City State ZIP Code

Phone

Terms

1) Interest will be charged on all invoices not paid within 30 days of the invoice date (2% per month or 24% annual rate)
2) All PAST DUE accounts are subject to Cash or Delivery (C.O.D.)
3) $400,00 yearly average is normally required for open account status.

In any event, if any charges(s) ever occurring on this account, are placed for collection or suit, I agree to pay all collection charges, costs, attorney fees, and legal interest on all charges not paid. In consideration of extending credit to the proceeding named, I do hereby guarantee the payment of such sum or sums of money as may be due to any work, service or goods purchased through Lefeld Welding & Steel Supplies, Inc.

I understand and agree to meet Lefeld Welding & Steel Supplies, Inc. terms of Net 30 days if an account is established. I also certify that all information given herein is true and correct, and authorize any credit inquiries necessary to establish this account.

Date*

Company Name*

Signed By*

Title*

This form must have signature of applicant, or authorized representative of applicant, before credit approval information can be obtained and charge account established. Thank You!

Email

This field is for validation purposes and should be left unchanged.

Charge Account Application

Terms