New Account Credit Application Step 1 of 3 - Contact Information 0% Which of the following is this Credit Application for:*ShurtapeEngineered Solutions GroupShurMedCustomer Name*Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Customer Phone*Customer FaxEmail Address* Company WebsiteDo you have an E-Commerce WebsiteYesNoSame URL as Company Website?YesNoE-Commerce URL Referring Shurtape Sales Rep / Sales Agency* Please send me news & marketing information (you can unsubscribe anytime) Additional InformationBusiness Start Date Date Format: MM slash DD slash YYYY Current Ownership Start Date Date Format: MM slash DD slash YYYY Type of OrganizationPlease SelectCorporationLimited Liability CompanySole ProprietershipPartnershipPurchasing Contact*Purchasing Contact Email* Sales ContactSales Contact Email Owner/Decision MakerOwner/Decision Maker Email AP Contact*AP Contact Email* Pricing ContactPricing Contact Email Late Notice ContactLate Notice Contact Email Credit Line RequestedCompany TypeHQBranch OfficePrimary Market Served*Arts & EntertainmentConstructionConvertor/PrinterElectricalHVACIndustrialInsulationPackagingPlumbingPrimary Market Served*ManufacturingConstructionPrimary Market Served*ManufacturingBuying GroupAffiliated Distributors - HVACAFFLINK PremierNetwork Services GroupBuying GroupBuying GroupAffiliated Distributors - HVACAFFLINK StandardNetPlus GroupNetwork Services GroupSphere1Buying GroupADAPTAffiliated DistributorsAFFLINK StandardEquity PlumbingEvergreen Marketing GroupIWDC GroupNetPlus GroupNetwork Services GroupSphere1Buying GroupAD-ElectricalCED AffiliateIMARKBuying GroupAffiliated DistributorsAFFLINK StandardNetPlus GroupThe United GroupBuying GroupAffiliated DistributorsAFFLINK PremierNetPlus GroupThe United GroupBuying GroupAffiliated Distributors - HVACBuying GroupThe United GroupFederal ID#Tax Exemption / Resale CertificateTax Exempt CertificateAccepted file types: xls, doc, pdf, xlsx, docx.This application will not be processed without a valid tax exemption certificate or resale certificate attached (except in the states of Alaska, Delaware, Montana, New Hampshire, & Oregon).Invoice Delivery Specification* Email Fax Mail Confirmation Delivery Specification* Email Fax Invoice Delivery Email Confirmation Delivery Email Invoice Delivery Fax #Confirmation Delivery Fax #Additional AttachementsPlease attach your Shipping, Labeling or Compliance Guides. Drop files here or Accepted file types: xls, doc, pdf, xlsx, docx. Reference #1Reference File Upload (doc, docx, xls, xlsx, pdf)Accepted file types: xls, doc, pdf, docx, xlsx.This application will not be processed without three references. You may upload a file containing your references or complete the fields below.Reference #1 NameReference #1 EmailReference #1 PhoneReference #1 FaxReference #1 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Reference #2Reference #2 NameReference #2 EmailReference #2 PhoneReference #2 FaxReference #2 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Reference #3Reference #3 NameReference #3 EmailReference #3 PhoneReference #3 FaxReference #3 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Bank NameBank Contact NameBank Contact EmailBank PhoneBank FaxBank Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country AcknowledgementThe undersigned hereby affirms that he/she has the authority to sign this document authorizing the bank to release information to Shurtape Technologies, LLC. The Applicant certifies that the information contained in this Application for Credit is true and correct and further agrees that Shurtape Technologies, LLC may turn to a credit reporting bureau for verification of the information provided. (Subsequent credit inquires may be completed by Shurtape Technologies, LLC in connection with any update, renewal or extension of credit.) The Applicant agrees to the following: Applicant herewith submits the within Application for Credit to: Shurtape Technologies, LLC as well as to their subsidiaries, divisions, affiliates and related companies. Applicant shall pay the full amount of the invoice(s) when due, which is defined to be thirty (30) days from the invoice date, unless otherwise agreed. Your Name*Your Email Your TitleSignature*
