* *
Street*
 
City* State*
 
Postal Code* Country*
Is this location responsible for the payment of invoices? *
Phone Number Fax Phone
Business is:*
Select OneHow many years has this business been in existence?*
Tax Exempt?*
*If yes, a copy of tax exempt or resale certificate must be attached. You may also attach any other standard form here.

Officers, Principal Owners, Parent Company, or Affiliated Companies

Title Phone Number
 
Email

Title Phone Number
 
Email

Title Phone Number
 
Email

Title Phone Number
 
Email

Banking References

Date

Primary Banking Relationship

Contact Person Account Number
 
Email

Trade References (Vendors with whom you do regular business on a credit basis)

Reference 1

Street Address
 
City State
 
Postal Code Country
Phone Number Email
 
Fax Number

Reference 2

Street Address
 
City State
 
Postal Code Country
Phone Number Email
 
Fax Number

Reference 3

Street Address
 
City State
 
Postal Code Country
Phone Number Email
 
Fax Number

AUTHORIZATION
Please read and sign below

I authorize Moss Inc. to obtain credit information about our accounts as listed. Our firm is financially able to meet any sales commitments made, and agree to pay Moss Inc. invoices according to the stated terms in return for extending credit to our company. In the event the payment is not made and this account is referred for collection, our firm will pay the cost of collection. Our firm understands interest on any unpaid balance will be charged at the highest rate authorized by law. If suit or action by an attorney is instituted, our firm agrees to pay reasonable attorney fees in said suit or action. It is understood that all billings of accounts receivables and credits are processed through Moss Inc. headquarters in Elk Grove Village, IL.

Date