Summers Rubber Company Company Credit Application

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Company Name *

Mailing Address *

Shipping Address *

Phone *

Fax *

Website

Sales Tax Status *

ExemptTaxable

Please note: Include a tax exempt certificate if you are claiming an exception.

File Upload

Purchasing Agent

Name *

Email *

Phone *

Fax *

Accounts Payable

Name *

A/P Phone *

A/P Fax *

A/P Email *

Please Indicate How You Would Like to Recieve Invoices *

MailFaxEmail

References (Telephone, Fax, and Account Numbers)

Credit Name & Email

Fax # for Credit Reference *

Credit Name & Email

Fax # for Credit Reference *

Credit Name & Email

Fax # for Credit Reference *

Bank *

Please provide us with the following information in order for us to serve you better:

Appx. Annual Sales

Number of Employees *

SIC Code *

Business Description

Credit Limit Requested *

--<$500<$1,000<$2,500<$5,000<$10,000<$25,000<$100,000

Authorized Person Completing This Form *

Title *

Date *

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