NEW ACCOUNT SET-UP FORM All items must be faxed to 312-662-5920 or emailed to
[email protected]. All company contact information must be filled out including a fax number, email, direct line and/or extensions, and the bottom must be signed and dated. Do not hesitate to contact your account rep or Elizabeth Gonzalez at 312-662-4720 if you have any questions. Company Information Company Name: Federal ID: Nature of Business: # of Employees: Address: Company Website: City, St, Zip: In Business Since: Contact/Phone: Bond/Stb: Fax: Type of Ownership: If Division/Subsidiary, Name of Parent Company: Address: City, St, Zip: Contact/Phone: Key Directors & Officers / Proprietors First/Last Name
Trade References Company
(Please Include Attachment If Additional Space Needed)
Phone
E-mail Address
Title
E-mail Address
Contact Name
(Please Include Attachment If Additional Space Needed)
Phone
Open Accounts References Company
Bank References Institution
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Accounting/Payment Contact Info Name/Title: Phone: E-mail:
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(Please Include Attachment If Additional Space Needed)
Phone
E-mail Address
Contact Name
E-mail Address
Contact Name/Title
(Please Include Attachment If Additional Space Needed)
Payment Processing Information 3rd Party Involved? If Yes, please provide… Company: Address: Phone:
Phone
Preferred Invoicing Method
Preferred Method of Payment
(Please Select One)
(Please Select One)
Mail E-mail Fax
Check ACH
I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied in order to verify the information contained herein. ***Note: Accounts may be placed on a HOLD status if payments are not received by the required due date.
The statement of facts on this document is certified to be correct
X (Print Name)
Title
Date