Dealer Application - United Supply Company

Type of Account?(Required)

New

Update

Dealer Information

Name of Business(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Business Phone(Required)

Business Fax

Cell Phone(Required)

Email Address(Required)

Do you have a different billing address?(Required)

Yes

No

Do you have a different shipping address?(Required)

Yes

No

Billing Address

If different than above

Street Address Address Line 2 City State ZIP Code

Shipping Address

If different than above

Street Address Address Line 2 City State ZIP Code

Type of Business(Required)

Purchase Order Required(Required)

Yes

No

Contacts

Accounts Payable Representative(Required)

Accounts Payable Phone

Credit Limit

Credit Limit Desired(Required)

Business Type(Required)

Corporation

Partnership

Sole Proprietorship

Do You Wish to Receive Emailed Invoices(Required)

Yes

No

Email(Required)

Officers, Partners, or Sole Proprietors

Contact #1(Required)

First Last

Contact #1 Title(Required)

Contact #1 Social Security Number(Required)

Contact #1 Phone(Required)

Contact #2

First Last

Contact #2 Title

Contact #2 Social Security Number

Contact #2 Phone

Tax Information

Federal ID #

Resale Tax ID #

In Business Since(Required)

Upload State Resale Tax Certificate

For additional information, contact USC Customer Service

Max. file size: 64 MB.

Credit Card Information (Optional)

Do you desire to charge purchases on your MasterCard or Visa credit card?

Yes

No

A United Supply Company representative will contact you shortly to record your credit card information.

The information furnished on this application is for the purpose of obtaining credit. I understand that this information will be relied on for the extension of credit. I hereby certify that the information is true, correct, and complete.
United Supply Company is authorized to report to the proper persons and bureaus the performance of this agreement.
Standard terms for invoices are net 30-days from the date of invoicing. Other specialized terms are available based on products and/or quantities purchased.
Upon default of the terms of this agreement, United Supply Company may declare my existing balance due and payable in full. Upon default of payment terms, United Supply Company may also collect for all attorney fees and/or collection fees associated with the collection of any past due balances.
Interest will be charged at the rate of 1.5% per month on past due amounts.
My signature on this credit application authorizes United Supply Company to obtain any credit information necessary to provide me with an account.

Company Name(Required)

Date(Required)

Please attach trade references if available

Max. file size: 64 MB.

CAPTCHA

Signature(Required)

Owner/Officer (application must be signed before account approval procedures)

Signature

Other Owner/Officer (application must be signed before account approval procedures)