Read Me First - OUR CREDIT POLICY to make sure you understand our Terms and Conditions of allowing you to purchase within our system on OPEN ACCOUNT TERMS.  Please complete this questionnaire and we will process your application.
How Did You Hear About Us:
Business Name:
Owner/Officer:
Address:
City, State, Zip:
Telephone:
Best Time To Call:
Fax:
E-mail of e-Procurement Authorizer within your company:
This is the email address of the person who approves all purchases within our system by the members of your organization.
Homepage URL:
Tax ID # or SS#
DUNS # or TRW#
New or Existing Business? New     Existing
Business Type:
Business Location:


Nature of Business:


Market Your Business?
Describe Products Sold:
Do You Want to be Notified by eMail of New Product Announcements, One Time Discounts and Quantity discounts? Yes     No
Are you Interested in an eProcurement System like ours for your clients to conduct their business with your company. Yes     No
Would you like to use our system to service your clients? It is transparent to them! Yes     No
Do You Have EDI Standard capabilities to transact business? Yes     No
Do You Expect to Pay by EFT (Electronic Funds Transfer)? Yes     No
Do You Want to Be placed on A Volume Discount Schedule? Yes     No
Estimate Monthly Average Transaction:
Estimate Maximum Transaction:
Estimate Monthly Transaction Volume:
Continue Only if you want Open Account Terms or Online Financing!

Please Rate Your Personal or Company Credit History:
Any Bankruptcies in the Last 3 Years: Yes     No
Notes or Comments:
Trade Reference Business Name:
Contact:
Address:
City, State, Zip:
Telephone:
Fax:
E-mail:
Trade Reference Business Name:
Contact:
Address:
City, State, Zip:
Telephone:
Fax:
E-mail:
Trade Reference Business Name:
Contact:
Address:
City, State, Zip:
Telephone:
Fax:
E-mail:
Trade Reference Business Name:
Contact:
Address:
City, State, Zip:
Telephone:
Fax:
E-mail:
Banking Reference Business Name:
Contact:
Address:
City, State, Zip:
Telephone:
Branch
Account #
Fax:
E-mail:

Please submit this form and your account status will be established and you will be notified by eMail of the changes.  Allow 7-10 days to process application.