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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.

Company Name*
Phone*
Fax
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Organization*
Year Established*
EIN (FED ID #):*
Name & Title of Person Requesting Credit:*
Billing/AP Contact Name:*
Phone*
Email*
Material Purchased for:*
Resale Certificate Number:*
List Name of Principal Corporate Office
Name*
First Last
Title*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
If there are additional owners please enter their full name, full address and phone numbers in the field below:
Bank Reference
Bank Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Contact*
Trade References
Please list references (USA references preferred):
Reference #1
Account Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email*
Reference #2
Account Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email*
Reference #3
Account Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email*
How did you hear about SJE Rhombus?
Consent
I hereby certify that all information provided is true and authorize SJE, Inc. to contact trade and bank references for normal credit information. The information being furnished to SJE, Inc. is for the purpose of extension of credit. The undersigned authorizes the above listed references to provide SJE, Inc. with information regarding account history. This authorization may include, but is not limited to, obtaining a credit report. A service charge of 1.5% per month may be incurred on all bills remaining unpaid after 30 days past agreed upon credit terms. If this account is placed in the office of a collection agency or attorney for collections, the undersigned shall pay an amount equal to 25% of the unpaid principal and interest as consideration for the extension of credit. This applies to the above business, and/or company, and/or successor companies.
Type Your Full Name*
Type Your Title*
Today's Date*
MM slash DD slash YYYY
Phone*
Consent*
I hereby certify that I am an Authorized Representative and have the Authority to submit this credit application request.
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Credit Application

List Name of Principal Corporate Office

Bank Reference

Trade References

Reference #1

Reference #2

Reference #3