Application For Credit Advanced Gases & Equipment | Welding | Gases

Business Contact Information

Date Of Application *

Date Business Commenced *

Month *

Day *

Year *

How many years at this address? *

Company Name *

DBA (If Any)

Website

Billing Street Address *

Billing Apartment, suite, etc

Billing City *

Billing State/Province *

Billing ZIP / Postal Code *

Billing Country

Is your shipping address the same as your billing? *YesNo

Shipping Street Address *

Shipping Apartment, suite, etc *

Shipping City *

Shipping State/Province *

Shipping ZIP / Postal Code *

Shipping Country

Accounts Payable Name *

Accounts Payable Email Address *

Accounts Payable Phone *

Purchaser Contact Name

Purchaser Phone Number

Purchaser Email Address

Bank Information

Bank Name *

Branch *Where is your bank located?

Account Types *SavingsCheckingOther

Other account type:

Trade/Business References

Reference #1

Company Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Type of Account *

Contact *

Phone *

Fax

Email Address

Do you have another Reference?YesNo

Reference #2

Company Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Type of Account *

Contact *

Phone *

Fax

Email Address

Do you have another Reference?YesNo

Reference #3

Company Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Type of Account *

Contact *

Phone *

Fax

Email Address

Agreement

How did you hear about us? *

Who did you speak with? *

Resale Certificate

No file chosen

You may upload your resale certificate here or email to [email protected]

Please Sign

Signature *