Credit Application

COMPANY LOCATION
Full Legal Company Name:*
Trade Name(s):
Physical Address:*
County:*
City:*
State/Province:*
Postal Code:*
Phone:*
Fax:*
Website:
Billing Address: Check here if billing address is different than physical address
Shipping Address: Check here if shipping address is different than physical address
CONTACT INFORMATION
Purchasing Contact:*
Email:*
Phone:*
Fax:*
A/P Contact:*
Email:*
Phone:*
Fax:*
COMPANY INFORMATION
Type of Business:*
Year Established:*
FEIN:*
-  
Is this company
Tax Exempt?
Has the company
ever filed bankruptcy?
Legal Entity:*
Parent Company:
PRINCIPALS/OFFICERS/KEY MANAGERS
Name:*
Title:*
Phone:*
VOLUME ESTIMATE
Period (Mo./Yr.):*
Product(s):*
Volume/Quantity:*
$ Amount:*
Mytex Polymers Sales Representative:
SIGNATURE
Applicant authorizes investigation of its credit to be used for all Mytex Polymer business purposes. Customer agrees Mytex Polymers Terms and Conditions of Sale shall govern all transactions using Mytex Polymers open account payment credit terms. Applicant agrees to pay all charges in full within the due date of the invoice and is responsible for all collection costs and attorney's fees.
Agreement:* I have read and agree to the above terms. 
Authorized Person's Name:*
Authorized Person's Initials:*
By initialing this form you agree that all information is accurate to the best of your knowledge. Your initials serve as your signature.
Title:*
Email Address for Confirmation:*
An email confirming the submission of this application will be sent to this address.