CPD Credit Application Form.

Applicants Home Address:
(this section must be filled out in order for this application to be processed)

Owner's Name:
Address:
Phone:
City/State/Zip:
County:

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Company Information:
(this section must be filled out in order for this application to be processed)

Company Name:
Company Phone:
Bill To Address:
Bill To City/State/Zip:
Bill To Fax:
Bill To County:
SHIP TO ADDRESS:
SHIP TO CITY/STATE/ZIP:
Accounts Payable Email:
Web Site Address:
Type of Business:
Year Established:

(Check One) Corporation Individual Partnership

Which of our product lines are you currently signed as a dealer for?

Previous Address:
Tax Exemption #:
Federal ID #:
Name of Accounts Payable contact(s):

By producing the electronic signature below I agree and understand that CPD's terms
are 1% 10^th, net 25  and I agree to pay within these terms. Also, by producing the
electronic signature below, I am giving authorization for my references listed, to release
credit information for the purpose of establishing an open account with CPD.

Owner's Electronic Signature:
Date:

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BANK INFORMATION

Institutions Name:
Street Address:
City/State/Zip:
Phone Number:
Fax Number:
Contact Person:
Account Number:

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TRADE REFERENCES
(Including fax numbers will speed up the processing time of your credit check)
** At Least 3 References Must Be Provided If You Are Applying For Open Account. **

Check here if you are applying for a COD or Credit Card Account.
       If Checked No Trade References Needed - Someone will contact you for further information.
  

Company Name:
Fax Number:
Account Number:

Company Name:
Fax Number:
Account Number:

Company Name:
Fax Number:
Account Number:

Company Name:
Fax Number:
Account Number:

          ** Please allow up to 14 business days for complete processing **