PRC Industrial Supply Credit Application

Company Name *

Mailing Address *

Shipping Address *

Phone *

Fax *

Website

Sales Tax Status *

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

File Upload

Purchasing Agent

Name *

Email *

Phone *

Fax *

Name *

A/P Phone *

A/P Fax *

A/P Email *

Please Indicate How You Would Like to Recieve Invoices *

Credit Name & Email

Fax # for Credit Reference *

Credit Name & Email

Fax # for Credit Reference *

Credit Name & Email

Fax # for Credit Reference *

Bank *

Appx. Annual Sales

Number of Employees *

SIC Code *

Business Description

Credit Limit Requested *

Authorized Person Completing This Form *

Title *

Date *

Captcha *

reCAPTCHA is required.

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