Customer Application for Open Account/Credit Policy & Agreement "*" indicates required fields Billing InformationName (Billing)* DBA/AKA* Billing Street Address* Billing City* Billing State*StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificBilling ZIP* Billing Phone*Billing FaxBilling Email* Website A/P Contact* A/P Phone*A/P Email* Location InformationLocation #1 Name* Location #1 Address* Location #1 City* Location #1 State*StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLocation #1 ZIP* Location #1 Contact* Location #1 Phone*Do you need to add another location? Yes No Location #2 Name* Location #2 Address* Location #2 City* Location #2 State*StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLocation #2 ZIP* Location #2 Contact* Location #2 Phone*Add a 3rd location? Yes No Location #3 Name* Location #3 Address* Location #3 City* Location #3 State*StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLocation #3 ZIP* Location #3 Contact* Location #3 Phone*Do you need to add more locations? Yes No Please upload a file listing more locations, thanks!Max. file size: 50 MB.For Washington locations please attach WA re‐seller’s permit if applicable.Max. file size: 50 MB.Would you like to receive invoices electronically?* Yes No Billing Email to receive invoices* Invoices will be mailed to the billing address above.Ownership* S Corp C Corp Partnership Sole Proprietor Owner(s) / Officers(s)* Federal Tax ID#* County* Trade ReferencesCompany #1Trade Reference Company #1 Contact Company Street Address City StateStateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP PhoneFaxCompany #2Reference Company #2 Contact Company Street Address City StateStateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP PhoneFaxQuotesWho is authorized to approve quotes?* Quotes to be sent to:* Will purchase orders be required?* Yes No ** Work orders will be included with your invoices.Would you like copies of work orders sent ahead of time electronically via email?* Yes No Email to send work orders to:* Credit Policy & AgreementThe following constitutes Northwest Mechanical Group’s credit policy, and in consideration of extension of credit, the undersigned does hereby agree to accept credit and payment of the account according to the following conditions: Customer agrees that all payments for labor and/or materials will be made within 30 days ofbilling. Any objections to labor and/or materials must be made within 7 business days, or such objections are waived. A finance charge of 1.5% per month (18% annually) will be assessed on any past due account. Any account 60 days past due can be placed on C.O.D. status until account is current. Northwest Mechanical Group will provide customer copies of any manufacturer’s written warranties covering products sold. In the event of warranty claim, the customer’s sole right is to make a claim under the warranty issued by the manufacturer. If the account is turned over to any attorney or collection agency for collection, the undersigned customer agrees he will be responsible for the costs of collection, including reasonable attorney’s fees and costs. The representations provided on this application are complete and accurate. I understand the information provided will be relied upon in the evaluation and extension of credit terms. I further certify that I fully understand the terms of credit as offered by Northwest Mechanical Group and agree to prompt payment in consideration of any extended credit. We will use all reasonable efforts to keep the above information confidential, & will use only to make a determination of credit worthiness, or for collection purposes in the event of non‐payment. By submitting this application, you authorize Northwest Mechanical Group to make inquiries into the business/trade references you have supplied.Printed Name of Applicant* Date* MM slash DD slash YYYY Signature*NameThis field is for validation purposes and should be left unchanged.
