Credit Application for Business Account

ATTENTION: Please complete all sections of this application to establish a credit account. The form will export a PDF that MUST be emailed to sales@stauffer-cisco.com. Completed applications are processed within 1-2 business days.

This form produces a downloadable PDF. Your information is deleted once the tab is closed.

Section 1 — Business Contact Information

Contact Title (e.g. Director, President) * Company Legal Name *

Phone * E-mail *

Registered Company Address * City * State * ZIP Code *

Date Business Commenced *

Business Type

Sole Proprietorship Partnership Corporation Other

Section 2 — Business and Credit Information

Primary Business Address (If different) City State ZIP Code

How long at current address? * Telephone * E-mail *

Bank Reference

Bank Name * Bank Phone *

Bank Address * City * State * ZIP Code *

Type of Account *

Checking Account Other

Account Number *

Section 3 - Business/Trade References

Two references required, one more optional.

Trade Reference 1

Company Name * Type of Account *

Address * City * State * ZIP Code *

Phone * E-mail *

Trade Reference 2

Company Name * Type of Account *

Address * City * State * ZIP Code *

Phone * E-mail *

Section 4 — Agreement

Once this PDF is emailed, the applicant acknowledges and agrees to the following terms and conditions of Stauffer-Cisco Supply:

All invoices are to be paid 30 days from the date of the invoice.

Claims arising from invoices must be made within seven working days.

By submitting this application, you authorize Stauffer-Cisco Supply to make inquiries into the banking and business/trade references that you have supplied.

Section 5 — Signatures

An authorized employee or owner must sign below.

Primary Authorized Signature

Sign here using your mouse, stylus, or finger

Print Name * Authorized Title * Date *

This form generates a downloadable PDF that MUST be emailed to sales@stauffer-cisco.com. Your data is not permanently stored.