PHP Customer Credit Application

PHP Distribution customers who intend to pay via Purchase Order and/or take advantage of our special terms or freight allowed qualifications are required to complete a credit application. Please complete the form below, or you can download a PDF credit application and email it to info@phpdistribution.com.

Company Information (step 1 of 5)

Company Name

Purchasing Agent

Phone Number

Accounts Payable Agent

Fax Number

Email Address

Billing Address

Billing City

Billing State

Billing Zip Code

Shipping Address

Shipping City

Shipping State

Shipping Zip Code

Ownership Type

Business Type

How long have you been at this location

Can we contact you with specials?

Corporation Information (step 2 of 5)

Legal Name

State of Incorporation

Date of Incorporation

Bank References (step 3 of 5)

Bank Name

State Sales Tax Exempt Number

Must fax in your certificate of exemption to: 800-255-7985

Sales Tax Exemption Form

Please upload a JPG, PNG or PDF of your Sales Tax Exemption Form to expedite your process. If you cannot upload a file, please fax your certificate to us at: 800-255-7985.

Savings Account Number

Checking Account Number

Bank Address

Bank Phone Number

Bank City

Bank State

Bank Zip Code

Supplier References (step 4 of 5)

Supplier #1 Name

Supplier #1 Phone Number

Supplier #1 Email

Supplier #1 Fax Number

Supplier #1 Account Number/Contact

Supplier #1 Address

Supplier #1 City

Supplier #1 State

Supplier #1 Zip Code

Supplier #2 Name

Supplier #2 Phone Number

Supplier #2 Fax Number

Supplier #2 Email

Supplier #2 Account Number/Contact

Supplier #2 City

Supplier #2 Address

Supplier #2 State

Supplier #2 Zip Code

Authorization & Completion (step 5 of 5)

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