ACCOUNT APPLICATION | WesternChemicalPumps

Customer Account Application Form

Business Legal Name

Phone

Requested Credit Amount (USD)

Fax

Company Website

Year Established

Provide details on any affiliated subsidiaries

Reseller Certificate

Upload File

Sales Tax Exempt Certificate

Upload File

Business Billing Address

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Principal, Executive, or Officer Contact Information

First name

Last name

Phone

Accounts Payable Contact Information

First Name

Last Name

Phone

Purchasing Contact Information

First Name

Last Name

Phone

Purchase Order numbers required?

Yes

Business Reference #1

First name

Last Name

Phone

Address

Business Reference #2

First name

Last Name

Phone

Address

Business Reference #3

First name

Last Name

Phone

Address

Bank Information

Bank Name

First name

Branch

Last Name

Phone

Address

I hereby verify the accuracy of the provided information and acknowledge the terms and conditions outlined by Western Chemical Pumps, Inc.

I grant authorization to Western Chemical Pumps, Inc. and its financial representatives to communicate with the listed references for the purpose of acquiring business-related details about this company. This includes the potential retrieval of bank reports if necessary for the establishment and ongoing monitoring of this account, with the aim of securing a line of credit in the course of our business relationship.

First name

Last name

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