Credit Application | Summit Facility Supply

Organization Name *

Year Established *

Primary Contact Name *

Bill-To Street Address *

Bill to City *

Bill-To State *

Bill-To Zip *

Ship-To Street Address (if different)

Ship-To City

Ship-To Zip

Primary Contact TEL *

Primary Contact Email *

Federal EIN #

Tax-Exempt?

Yes

If yes, please attach exemption certificate

Primary Industry *

Desired Credit Amount *

Bank Name *

Bank Account Number *

Bank Contact

Bank Phone *

Trade Reference 1 Name

Trade Reference 1 phone or e-mail

Trade Reference 2 Name

Trade Reference 2 phone or e-mail

Do you Authorize Summit to contact your credit references? *

Submit

Thank you for submitting your credit application.