Credit Application

1 Step 1

Your Namefirst and last

Company NameNeeds to be exact company name, not your DBA

Phone

Federal Tax ID

Billing addressStreet, city, state

Is your billing and shipping address the same

YesNo

Shipping addressStreet, city, state

Type of business

Expected Volume of Ordersplease provide an estimated dollar amount

Existing Brass Fitting Suppliersplease provide the names of all existing suppliers

Name of your company's bank

Bank's address

Reference #1

Business name and contact nameplease provide both pieces of information if available

Contact informationplease provide phone, email and address if available

Reference #2

Business name and contact nameplease provide both pieces of information if available

Contact informationplease provide phone, email and address if available

Reference #3

Business name and contact nameplease provide both pieces of information if available

Contact informationplease provide phone, email and address if available

I agree to the terms below

Yes

Applicant's signature attests financial responsibility, ability, and willingness to: Pay our invoices in accordance with terms stated on invoices. There will be a 1.5% per month service charge on invoices past due. The above information is for the purpose of obtaining credit and is warranted to be true. We hereby authorize Couplings Company, Inc. to investigate the references listed pertaining to our credit and financial responsibility. This application will be regarded as confidential material.

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