Credit Application

USA & Global Customers

Fill out the information below and submit.

Legal Name of Business*
Doing Business As (DBA)*
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Completed By*
Federal ID Number*
V.A.T. Number (International Customers Only)
Year Business Established*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Limit Requested ($)*
Phone*
Email to Send Invoices*
Accounts Payable Manager*
First Last
Accounts Payable Manager Direct Phone*
Accounts Payable Manager Email*
Accounts Payable Contact*
First Last
Accounts Payable Contact Direct Phone*
Accounts Payable Contact Email*
Ownership*
International Please Provide (Srl, GmbH, etc)
Principal Owners and/or Officers*
Name Title
Additional Owners/Officers
Name Title
Product Line*
Applicant certifies that all information contained herein is true and correct. Applicant grants permission to Clark-Reliance Corporation to obtain independent credit reports and other information from its references and bank; and authorizes the credit references to release information to Clark-Reliance that may be used to determine credit worthiness. Applicant agrees to pay all costs of collection, including actual out-of-pocket expenses and collection fee of eighteen percent (18%), if collected through a collection agency or attorney. This credit agreement will be governed by the laws of the State of Ohio. The undersigned applicant states that I am authorized to execute this agreement on behalf of the applicant.