RELECTRIC - Electric supply products, circuit breakers
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Online Credit Application

Please complete the application below. If you'd prefer a printer friendly version for fax submission, please click here.

General Business Information

Business Name:
Tax ID# (EIN or SSN):
Tax Exemption #:
Note: Please fax tax exemption certificate to (800) 504-0255

Dun & Bradstreet # (DUNS):

Contact Information

Contact Person:
Telephone:
Fax:
Email:

Mailing Address

Street (No PO Box):
City:
State:
Zip Code:

Billing Address (if different)

Street Address:
City:
State:
Zip Code:

Management Information

Please detail the ownership information of your company.

Owner / Officer #1

Name: Title:
Home Address: Phone:
State: Zip: % Owned:

Owner / Officer #2

Name: Title:
Home Address: Phone:
State: Zip: % Owned:

Owner / Officer #3

Name: Title:
Home Address: Phone:
State: Zip: % Owned:

Owner / Officer #4

Name: Title:
Home Address: Phone:
State: Zip: % Owned:

Business Description

State Registered:
Date:
Structure:
Nature of Business:
Gross Annual Sales:
Accounts Payable Contact:
Accounts Payable Phone:

Bank Reference

Bank Name:
Street Address:
City:
Account Type:
State:
Zip Code:
Telephone Number:

Commercial References

Please provide at least four trade references.

Reference #1

Business Name: URL:
Street Address: Phone:
State: Zip: Fax:

Reference #2

Business Name: URL:
Street Address: Phone:
State: Zip: Fax:

Reference #3

Business Name: URL:
Street Address: Phone:
State: Zip: Fax:

Reference #4

Business Name: URL:
Street Address: Phone:
State: Zip: Fax:

Acknowledgement and Agreement to Terms and Conditions

Applicant agrees that Applicant's purchase of goods from and Relectric Supply Inc., and Relectric Supply Company, LLC's sale of goods to Applicant, shall be subject to Relectric Supply Company, LLC's Terms and Conditions of Sale (see text box below), and to the provisions of Relectric Supply Company, LLC's Order Acknowledgments and Invoices, as any of the same may be changed from time to time by Relectric Inc.

ON BEHALF OF APPLICANT AND THE OWNERS WHOSE NAMES APPEAR ABOVE, AND IN ORDER TO INDUCE Relectric Supply Company, LLC TO SELL GOODS TO APPLICANT, I CERTIFY, REPRESENT, AND WARRANT THAT ALL OF THE INFORMATION IN THIS APPLICATION IS TRUE AND CORRECT, AND DULY AUTHORIZE Relectric Supply Company, LLC TO OBTAIN CREDIT REPORTS ON APPLICANT AND ITS OWNERS.

Name:
Title:
Date:

  

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