New Account Credit Application Step 1 of 3 - Contact Information 0% Which of the following is this Credit Application for:* Shurtape Engineered Solutions Group ShurMed Customer Name* Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Customer Phone*Customer FaxEmail Address* Company Website Do you have an E-Commerce Website Yes No Same URL as Company Website? Yes No E-Commerce URL Referring Shurtape Sales Rep / Sales Agency* Please send me news & marketing information (you can unsubscribe anytime) Additional InformationBusiness Start Date MM slash DD slash YYYY Current Ownership Start Date MM slash DD slash YYYY Type of OrganizationPlease SelectCorporationLimited Liability CompanySole ProprietershipPartnershipPurchasing Contact* Purchasing Contact Email* Sales Contact Sales Contact Email Owner/Decision Maker Owner/Decision Maker Email AP Contact* AP Contact Email* Pricing Contact Pricing Contact Email Late Notice Contact Late Notice Contact Email Credit Line Requested Company Type HQ Branch Office Primary Market Served* Arts & Entertainment Construction Convertor/Printer Electrical HVAC Industrial Insulation Packaging Plumbing Primary Market Served* Manufacturing Construction Primary Market Served* Manufacturing Buying Group Affiliated Distributors - HVAC AFFLINK Premier Network Services Group Buying Group Buying Group Affiliated Distributors - HVAC AFFLINK Standard NetPlus Group Network Services Group Sphere1 Buying Group ADAPT Affiliated Distributors AFFLINK Standard Equity Plumbing Evergreen Marketing Group IWDC Group NetPlus Group Network Services Group Sphere1 Buying Group AD-Electrical CED Affiliate IMARK Buying Group Affiliated Distributors AFFLINK Standard NetPlus Group The United Group Buying Group Affiliated Distributors AFFLINK Premier NetPlus Group The United Group Buying Group Affiliated Distributors - HVAC Buying Group The United Group Federal ID# Tax Exemption / Resale Certificate Tax Exempt CertificateAccepted file types: xls, doc, pdf, xlsx, docx, Max. file size: 256 MB.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 Select files Accepted file types: xls, doc, pdf, xlsx, docx, Max. file size: 256 MB, Max. files: 6. Reference #1Reference File Upload (doc, docx, xls, xlsx, pdf)Accepted file types: xls, doc, pdf, docx, xlsx, Max. file size: 256 MB.This application will not be processed without three references. You may upload a file containing your references or complete the fields below.Reference #1 Name Reference #1 Email Reference #1 PhoneReference #1 FaxReference #1 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Reference #2Reference #2 Name Reference #2 Email Reference #2 PhoneReference #2 FaxReference #2 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Reference #3Reference #3 Name Reference #3 Email Reference #3 PhoneReference #3 FaxReference #3 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CanadaUnited States Country Bank Name Bank Contact Name Bank Contact Email Bank 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 Title Signature*
