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)