Company:

Date Established:

CEO or Owner Name:

Federal ID #:

Accounts Payable Contact Name:

Accounts Payable Contact Phone:

Accounts Payable Contact FAX:

Accounts Payable Contact Email:

Billing Address:

Shipping Address (if different than billing)

Company Type:

Corporation Sole Propietorship Partnership or LLC Non-Profit

Receive Invoices*:

By Email:

Or By Fax:

* Crowder Supply does not send invoices by US Mail.

Trade References

Company 1

Contact Name:

Contact Phone:

Contact FAX:

Company 2

Contact Name:

Contact Phone:

Contact FAX:

Company 3

Contact Name:

Contact Phone:

Contact FAX:

Bank Reference

Bank Name:

Checking Account Number:

Bank Contact:

Bank Phone:

Bank FAX:

Terms:

NET 30 with approved credit. We also accept all major US credit cards and Bank wire transfers. A $25 transfer fee will applied to your order.

Credit terms:

If credit is granted (I) (We) promise to pay all invoices when rendered. (I) (We) understand all invoices are payable 30 days after invoice date and that a service charge of 1 ½ % per month will be added to (my) (our) past due amount balance. IN the event payment is not received and (my) (our) account is placed for collection, (I) (we) will pay all costs of collection. If legal action is required (I) (We) will pay all reasonable attorney’s fees resulting from such action.

I Accept Terms

Your Name:

Your Title:

Questions or Comments: