PHP New Customer Credit Application

* Company Name:

Please enter company name.

* Purchasing Agent:

Please enter the purchasing agent.

* Phone Number:

Please enter your phone number.

* Accounts Payable Agent:

Please enter the accounts payable agent.

* Fax Number:

Please enter a fax number.

* Email Address:

Please enter an email address.Please re-format the email address.

* New Web Account Password:
(used for your new account)

Once approved we'll use this password for your account login.

* Shipping Address:

Please enter a shipping address.

* Billing Address:

Please enter a billing address.

* Shipping City:

Please enter the ship to city.

* Billing City:

Please enter the bill to city.

* Shipping State:

Please enter the ship to state.

* Billing State:

Please enter the bill to state.

* Shipping Zip Code:

Please enter the ship to zip code.

* Billing Zip Code:

Please enter the bill to zip code.

* Ownership Type:

Please Select Corporation Partnership Sole Proprietor Other Please select the ownership type.

How long have you been at this location:

* Business Type:

Please Select Contractor Supply Rental Store Agr. Farm Supply Lumber Yard Concrete-Redi Mix Lawn & Garden Hardware Small Engine Repair Electric Motor HVAC STAFDA LP Dealer Electric Wholesaler Golf Courses Contractor Other Please select a business type.

* Can we contact you with specials?

Please Select Yes No Thanks Please make a selection.

* Legal Name:

Please enter the legal name.

* State of Incorporation:

Please enter the state of incorporation.

* Date of Incorporation:

Please enter the date of incorporation.

* Bank Name:

Please enter your bank name.

* State Sales Tax Exempt Number:

Please enter the state sales tax exempt number.

* must fax in your certificate of exemption

* Savings Account Number:

Please enter the savings account number.

* Checking Account Number:

Please enter the checking account number.

* Bank Address:

Please enter the bank address.

* Bank Phone Number:

Please enter the bank phone number.

* Bank City:

Please enter the bank city.

* Bank State:

Please enter the bank state.

* Bank Zip Code:

Please enter the bank zip code.

* Name:

Please enter supplier name.

* Name:

Please enter supplier name.

* Phone Number:

Please enter the supplier phone number.

* Phone Number:

Please enter the supplier phone number.

* Fax Number:

Please enter the supplier fax number.

* Fax Number:

Please enter the supplier fax number.

* Account Number / Contact:

Please enter supplier account number.

* Account Number / Contact:

Please enter supplier account number.

* Address:

Please enter supplier address.

* Address:

Please enter supplier address.

* City:

Please enter supplier city.

* City:

Please enter supplier city.

* State:

Please enter supplier state.

* State:

Please enter supplier state.

* Zip Code:

Please enter supplier zip code.

* Zip Code:

Please enter supplier zip code

In support of this application, PHP is hereby authorized to obtain credit and/or financial information from my/our bank(s), other financial institutions or commercial firms with whom I/we have done business. It is understood that any such credit and/or financial information will be held in strict confidence and used only in consideration of this application.

Upon approval of this application, it is agreed that all purchases will be paid in full and in accordance with the terms of sale as stated on PHP invoice(s). Should I/we not pay PHP according to terms, it is understood that credit privileges may be withdrawn. Should PHP find it necessary to obtain assistance in collecting any past due balance, I/we agree to pay interest at the rate of 1.5% per month (or such other rate allowable by State law), reasonable attorney fees, collection fees, and/or court costs allowable by law. A copy of this statement and application has been received.

Authorized Signature

To sign this application, please, enter your name and e-mail address.

All statements made herein are true and accurate to the best of the undersigned’s knowledge. The undersigned authorizes PHP to make any and all inquiries necessary for action on this credit application. Each of the undersigned and its principal, hereby, indemnifies PHP and its agents from any liability resulting from this credit application. The applicant’s credit account may be suspended by PHP at any time.

By submitting this application electronically, the undersigned agrees that he/she is electronically signing this credit application and such electronic signature shall be treated as an affirmation that he/she is an authorized representative of the applicant seeking credit. The typed version of the undersigned’s name is being accepted as the undersigned’s original signature pursuant to applicable federal and/or state law.

* Digital Signature Name:

Please enter digital signature name.

Please enter an email address.Please re-format the email address.