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Credit Application
Step
1
of
8
12%
Requirements for Credit Application
*
Open Account (Projected purchases min. $2,400/year)
Are you a current CK Supply Customer?
*
Yes
No
If Yes, Please Provide Account Number (If Known)
Your CK Supply Account Manager (If Known)
Date
MM slash DD slash YYYY
Name of Firm
FEIN or SSN #
Billing Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Physical Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Headquarters Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Main Phone
Fax
Email
Main Contacts
Key Employee
First
Last
Title
President
CEO
CFO
Owner
Partner
Other
Key Employee
First
Last
Title
President
CEO
CFO
Owner
Partner
Other
Are You
Please select one.
A Corporation
A Partnership
A Proprietorship
Other
State Incorporated In
Type of Business
Please select the segment that best fits your business.
Manufacturing
Universities/Research/Laboratory/Medical
Construction/Contractor
Food & Beverage
Government & Municipalities
Metal Fabrication
Mechanical Contractor
Dry Ice
Scrap Metal
Cannabis
Years in Business
Tax Exemption Number
Please Upload Your Tax Exemption
Max. file size: 10 MB.
Are Purchase Orders Required?
Yes
No
Will you accept invoices by email?
Yes
No
If Yes, please provide email below!
Email
Do you want access to an online customer portal for your account?
Online Ordering, View Invoices, Order History, Account Balances, Credit Memos, Cylinder Balances, Open Orders, Pay Bill with a Credit Card, & More!
Yes
No
Email for Portal Access
Accounts Payable Contact Information
First
Last
Phone
Fax
Email
Our Credit Policy is Net 30 Days
I understand that the information furnished above is for the purpose of obtaining credit from your u001erm. I fully understand your credit policy and agree to your payment terms. I am authorized in my capacity, to bind my u001erm accordingly. I agree that all accounts or monies due shall be due and payable at your business. I understand and agree that all past due invoices shall automatically accrue interest at the rate of eighteen percent (18%) per annum and further agree to pay these charges. Should it become necessary to place this account with any attorney for collection, it is agreed that I/MY firm will be responsible for any and all costs of collection, including reasonable attorney’s fees.
Name
First
Last
Title (Officer/Owner)
Signature
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