Mail: PO Box 1111
Renton WA 98057-1111
Phone: 425 277-1011
Fax: 425 277-5266
CUSTOMER CREDIT & ACCOUNT INFORMATION
Please enclose your signed standard credit references or print and return this one with your order.
Firm Name: Federal EIN #
Bill to the attention of:
Billing Address:
City: State: Zip:
Shipping Address:
City: State: Zip:
Business Phone _______________________
Business Fax ________________________
Number of years in business ______________
Type of business __ Sole Proprietor; __ Partnership; ___ LLC; ___Corporation
Names & Address of Owners, Partners or Officers
Name Title Address City State Zip Phone
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Bank, Branch, Phone Contact Name and Phone
__________________________________________________________________
Credit References (not including bank card or oil company cards)
Name Address City State Zip Phone
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Anticipated monthly purchases from us: ________
Is a purchase order required? ____Yes ____No
Who is authorized to make purchases_________________
Should we charge WA State sales tax, except for items specified for your use?
Provide a statement of resale exemption:
The above information is being provided for the purpose of securing credit for purchasing. I understand that the terms for payment are 30 days net and that past due balances will be assessed a finance charge.
J. Fillips LLC places overdue accounts on shipping hold.
I certify to the best of my knowledge that the above information is correct and I accept the terms.
By ______________________________
(signature)
Name and Title______________________
(printed)