SJE-Rhombus Credit Application

PLEASE FILL OUT THIS APPLICATION IN ITS ENTIRETY. Information given below will be held confidential and is exclusively for our use.

This application must be filled out in English.

SJE-Rhombus CREDIT APPLICATION

Company Name:

A value is required.

(if Subsidiary)
Parent Company:

Parent Address:

A value is required.

City:

A value is required.

State:

A value is required.

Postal Code:

A value is required.Please enter a five digit zip code.

Billing AP Contact Telephone:

A value is required.Invalid format. (xxx) xxx-xxxx

Fax:

A value is required.Invalid format. (xxx) xxx-xxxx

EIN (FED ID #):

A value is required.

Shippng Address:

A value is required.

City:

A value is required.

State:

A value is required.

Postal Code:

A value is required.Please enter a five digit zip code.

Telephone:

A value is required.Invalid format. (xxx) xxx-xxxx

Fax:

A value is required.Invalid format. (xxx) xxx-xxxx

Full Name and Title
of Person Requesting Credit:

A value is required.

E-mail Address:

A value is required.Please enter a valid e-mail address.

Requested Credit Limit:

A value is required.

Sales Manager:

A value is required.

Authorized Purchasing Agent:

A value is required.

What do you estimated your monthly purchases to be?

A value is required.

Type of Organization:

Please select an item.

Material Purchased For:

Please select an item.

Type of Business:

Please select an item.

Resale Certificate #

State Issued:

Number of Years in Business:

A value is required.

Listed in Dun & Bradstreet?

Yes
No
Please make a selection.

if Yes, List D&B Number:

PRINCIPAL OWNER:

Full Name:

A value is required.

Physical Address:

A value is required.

City:

A value is required.

State:

A value is required.

Postal Code:

A value is required.Please enter a five digit zip code.

Phone:

A value is required.Invalid format. (xxx) xxx-xxxx

Fax:

A value is required.Invalid format. (xxx) xxx-xxxx

If there are additional owners please enter their full name, full address and phone numbers in the field below:

BANK REFERCE:

Full Bank Name:

A value is required.

Account Number:

A value is required.

Address:

A value is required.

Contact:

A value is required.

City:

A value is required.

State:

A value is required.

Postal Code:

A value is required.Please enter a five digit zip code.

Phone:

A value is required.Invalid format. (xxx) xxx-xxxx

Fax:

A value is required.Invalid format. (xxx) xxx-xxxx

TRADE REFERENCES: Please list references (USA refrences preferred)

Reference 1

Company Name:

Contact:

Address:

City:

State:

Postal Code:

Phone:

(xxx) xxx-xxxx

Fax:

(xxx) xxx-xxxx

Reference 2

Company Name:

Contact:

Address:

City:

State:

Postal Code:

Phone:

(xxx) xxx-xxxx

Fax:

(xxx) xxx-xxxx

Reference 3

Company Name:

Contact:

Address:

City:

State:

Postal Code:

Phone:

(xxx) xxx-xxxx

Fax:

(xxx) xxx-xxxx

How did you hear about SJE-Rhombus?

Please make a selection.

I hereby certify that all information provided is true and authorize SJE-Rhombus, to contact our trade and bank references for normal credit information. This information is furnished to SJE-Rhombus for the purpose of an extension of credit. We authorize the above listed references to provide SJE-Rhombus with information regarding our account history. I understand and agree to pay within the terms offered by SJE-Rhombus.

Type Your Full Name:

A value is required.

Type Your Title:

A value is required.

Today's Date:

A value is required.Invalid format. mm/dd/yy

Please make a selection.

I hereby certify that I am an Autorhized Representative and have the Authority to submit this credit application request.

Security Verification: