Credit Application

COMPANY INFORMATION

* Indicates required field

COMPANY NAME *

TRADE NAME *

NUMBER OF YEARS UNDER CURRENT OWNERSHIP *

INCORPORATION DATE *

STATE *

REGISTRATION NO *

ANTICIPATED ANNUAL PURCHASE (US $) *

REQUESTED CREDIT LIMIT (US $) *

ARE PURCHASE ORDERS RAISED TO PLACE ORDERS? *

Yes No

IF NO, HOW ARE ORDERS PLACED? *

BILLING INFORMATION

Phone Number *

FAX *

Email *

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

SHIPPING INFORMATION

Phone Number *

FAX *

Email *

Shipping Address *

Line 1

Line 2

City

State

Zip Code

Country

ACCOUNTS PAYABLE INFORMATION

Name *

First

Last

TITLE *

Phone Number *

FAX *

Email *

TAX INFORMATION

TAX PAYER ID *

TAX EXEMPT: (IF YES, ATTACH A COPY OF EXEMPTION CERTIFICATE) *

Yes No

Exemption Certificate *

Max file size: 20MB

BANK DETAILS

NAME OF BANK *

CONTACT PERSON *

ACCOUNT NUMBER *

Phone Number *

FAX *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

TRADE REFERENCES

Trade Reference No.1

Company Name *

Phone Number *

fax *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Trade Reference No. 2

company name *

Phone Number *

fax *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Trade Reference No. 3

company name *

Phone Number *

fax *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

DECLARATION

This information is submitted to Barney's Pumps, Inc. (the Company) for the purpose of establishing a business relationship and determining credit terms. The Company reserves the right to decline credit to the applicant, and, in the event where credit is extended to an applicant, the Company reserves the right to change or revoke an applicant's financial conditions and/or payment records. By signing this application, the applicant certifies that all information provided is correct and to the best of the applicant's knowledge. Applicant hereby authorizes the release of credit and banking information listed on this application. This form may be reproduced or photocopied, and a faxed/scanned copy shall be as effective consent as the original, which has been signed.

By signing this document, you agree to Barney's Pumps Terms of Sale and Warranty.

All orders process per Barney's Pumps standards terms and conditions of sale, and all terms and conditions of Barney's Pumps Terms of Sale and Warranty are incorporated herein by this reference as if fully set forth herein. Please see attached or visit https://www.barneyspumps.com/legal.html.

Name *

First

Last

Title *

Date *

Submit