WinSynergy Chemical – Credit Application

Customer Information

(* indicates required field)

Amount Applying For *

Name of Business *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Delivery Address (leave blank if same as billing)

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone *

DUNS Number

Fed. EIN

Type of Business

Date Business Started *

State of Incorporation *

Number of Employees *

Type of Business

Frequency of Orders

Size of Orders

Principal Owners and Officers

1: Name and Title *

2: Name and Title

3: Name and Title

Accounts Payable Contact Name *

Accounts Payable Contact Email *

Accounts Payable Phone *

Trade References (List 3 Major Suppliers)

Reference 1: Name *

Reference 1: Phone

Reference 1: Email *

Reference 1: Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2: Name

Reference 2: Phone

Reference 2: Email

Reference 2: Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3: Name

Reference 3: Phone

Reference 3: Email

Reference 3: Address

Address Line 1

Address Line 2

City

State

Zip Code

Bank References

Bank 1 Name *

Bank 1 Account Number

Bank 1 Officer

Bank 1 Email *

Bank 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Bank 2 Name

Bank 2 Officer

Bank 2 Email

Bank 2 Account Number

Bank 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Exemption Status

Will Sales Tax Be Exempt? *

If Yes, State Tax Exempt Number

(Please also email a copy of your tax exempt certificate)

Agreement

I, (we) certify that this information is true and correct and I, (we) give WinSynergy Chemical, LLC permission to contact any credit reporting agency, including the bank and trade references given and that any extension of credit shall be subject to the following terms and conditions:

1. Applicant affirms that it is authorized to do business within the State of Texas.

2. I, (we) shall pay the full amount of the invoice when due, which is defined as 30 days from the invoice date unless otherwise specified.

3. By typing their name, Applicant affirms that they have the authority to apply for credit on behalf of their firm.

Agreement Accepted for (Firm Name) *

Authorized Principal/Officer *

Title *

Date *

WinSynergy Chemical – Credit Application

Customer Information

Principal Owners and Officers

Trade References (List 3 Major Suppliers)

Bank References

Exemption Status

Agreement

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