Account Application

Company Name:
Account Number:

Billing Address

Address Line 1:
Address Line 2:
City:
State:
ZIP:
Phone:
Fax:
Email:

Shipping Address

Address Line 1:
Address Line 2:
City:
State:
ZIP:

Business Information

Type of Business:
Number of Years in Business:
Check one:
Years at present location:
Type of Organization:


      
Federal ID or SSN:
Tax Exempt:
   Tax-exempt #:

Principals

Principal #1
Principal Name:
Home Address:
City:
State:
ZIP:
Phone:
Principal #2
Principal Name:
Home Address:
City:
State:
ZIP:
Phone:
Principal #3
Principal Name:
Home Address:
City:
State:
ZIP:
Phone:

Bank Reference

Bank Name:
Account #:
Address:
City:
State:
ZIP:
Phone:

Trade References

(minimum of 3)
Trade Reference #1
Name:
Account #:
Address:
City:
State:
ZIP:
Phone:
Fax #:
Trade Reference #2
Name:
Account #:
Address:
City:
State:
ZIP:
Phone:
Fax #:
Trade Reference #3
Name:
Account #:
Address:
City:
State:
ZIP:
Phone:
Fax #:
Trade Reference #4
Name:
Account #:
Address:
City:
State:
ZIP:
Phone:
Fax #:

Credit Limit Requested:

Annual Sales:

Principal or Owner Making Application:
Title:
Order Pending?
Order Type:


In making this application for credit, the customer agrees to pay all invoices within the terms of our invoice. Customer agrees to pay a service charge of 1&1/2% per month, which is an annual percentage rate of 18%, on all overdue balances. Customer agrees to pay a $30 fee for all checks returned for insufficient funds. In the event a suit is necessary to collect any amount, the customer agrees to pay the seller’s collection fees, reasonable attorney fees and costs including attorney fees for appeal. The venue of any suit to collect this account may be held in Suffolk County, NY. This electronic application gives permission to Omega Moulding and its affiliates to request credit information at any time from the listed references above, including bank information, for the purpose of extending or adjusting credit terms.

Note: Many vendors will only grant credit information in writing. Therefore, please allow a 2-week minimum for your application to be processed. All orders will ship COD until references are returned. If you would prefer to use a valid credit card, please request our credit card authorization form.