Credit Application

Complete and submit the form below, or download file here and submit via fax (614-864-0435) or email.

company name

Shipping address

Billing addressCheck if same as shipping address

accounts payable contact

requested payment terms (please select one)net 30codcredit card

credit references are required for 30 day terms. payment terms are granted based on credit worthiness

email invoices?yesno

shipping informationTRUCK shipments will be sent prepaid and add if no collect number is present

trade references

What is your company tax statustaxedEXEMPT

submit w-9 (required)

Upload File

Max file size 10MB.

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fileuploaded.jpg

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submit Tax Exempt or Resale Certification

Upload File

Max file size 10MB.

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fileuploaded.jpg

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what type of business are you?END userdealeroem

We certify that the above information is true and correct. I/We agree to pay this accounting accordance with the credit terms established above. We authorize Mid-State Sales Inc. to verify this information and or obtain additional information by securing data from a credit agency.

form 7101.99
rev 06/20

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