BLACOH Fluid Control Credit Application

 All information is confidential.

Company Information

Company Name *
Billing Address *			City
State/Province *	Zip/Postal Code *	Country	Main Phone *	Main Fax
Shipping Address (No PO Box) * Same as Billing			City
State/Province *	Zip/Postal Code *	Country	Main Phone *	Main Fax

Primary Sales Contact	Email Address	Sales Phone
Primary A/P Contact *	Email Address *	A/P Phone *

Other Sales Branch Information  (Skip)

Company Name
Billing Address			City
State/Province	Zip/Postal Code	Country	Main Phone	Main Fax
Shipping Address (No PO Box)			City
State/Province	Zip/Postal Code	Country	Main Phone	Main Fax

Primary Sales Contact	Email Address	Sales Phone
Primary A/P Contact	Email Address	A/P Phone

Other Sales Branch Information - Continued (Skip)

Company Name
Billing Address			City
State/Province	Zip/Postal Code	Country	Main Phone	Main Fax
Shipping Address (No PO Box)			City
State/Province	Zip/Postal Code	Country	Main Phone	Main Fax

Primary Sales Contact	Email Address	Sales Phone
Primary A/P Contact	Email Address	A/P Phone

Business Profile

Organized As *
Individual/Sole Proprietorship C Corporation S Corporation Partnership Trust/estate LLC Other Not Applicable
Please choose the Limited Liability Company Tax Classification *
C Corporation S Corporation Partnership
Date Business was Established *	Have you done business under another name? If so, what name?
Under the Laws of (State/Province/Country) *	FED Tax ID *

Owners (if applicant is a sole proprietorship or partnership) Officers (if a corporation)

Name *	Title *	SSN	Phone *	Address *

Estimated Monthly Purchase *

W-9

Please submit a W-9 with your credit application. If you have your own W-9 to attach, please select it by using the "Choose File" option below. If you don’t have a W-9, please download a blank form here. You can also download a partially completed W-9 after submitting your application, and email it separately to Siobahn@Blacoh.com.

Select file:
	Allowed file types: pdf Maximum file size: 4Mb

Sales Tax/Resale Certification

Please select the appropriate option below.

Sales are Taxable Sales are Exempt (Attach resale cert. below) No Sales Tax

Select file: * Allowed file types: pdf Maximum file size: 4Mb

Web Disclaimer

To avoid having to agree to the web disclaimer each time you login to the website, you can submit a PDF of the disclaimer for Blacoh to keep on file. To do so, download, sign and date a hard copy of the Web Disclaimer. Then, submit a PDF copy of your signed Disclaimer by clicking 'Browse...' and selecting your file below. Click here to download the Web Disclaimer (PDF).

Select file:
	Allowed file types: pdf Maximum file size: 4Mb

Business and Bank References

Optionally, if you have your own document with your Business and Bank References you can upload them on the next step.

I have my own reference document(s) that I will attach to the application.

Signature

The undersigned ("Customer") states that all of the foregoing information is correct and requests that BLACOH Fluid Control, Inc. extend credit, and/or continue previously extended credit to the Customer. To assist BLACOH Fluid Control, Inc. in determining the nature and extent of credit, if any, to be extended or continued, Customer hereby authorizes BLACOH Fluid Control, Inc. to obtain credit reports and to investigate any credit and financial records, including banking records, which are in the name of the Customer or its principal officers and owners. Customer hereby directs any credit bureau, credit reporting agency and any other person, agency or firm having data or information concerning Customer or its principal officers and owners to accept a photocopy of this authorization as Customer’s release and direction to furnish copies of all such data and information to BLACOH Fluid Control, Inc.

Customer agrees to assume full responsibility for all purchases made on Customer’s account and to pay all bills when due. Customer agrees to not exceed the credit limits set forth and in the event Customer does exceed such limits, Customer agrees to assume full responsibility and to pay additionally any such amounts which exceed the credit limits previously set.

Should BLACOH Fluid Control, Inc. refer this account to any attorney or agency for collections, Customer will pay all cost, expenses, including attorney’s fees and court cost, incurred by or on behalf of BLACOH Fluid Control, Inc. and any such amounts not promptly paid upon demand shall be added to the unpaid balance.

It is understood and agreed that I/Customer will pay all charges according to BLACOH Fluid Control Inc.'s credit terms, including but not limited to any reasonable attorney and collection fees plus interest, as applicable. Entering full name and title in the column below will be treated as signature.

Owner/Partner/Officer Name *	Title *	Date * *