Credit Application

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Pay Your Bill

Please Complete This Form to Submit a

If you would rather print this Credit Application and mail it to us, please use the pdf version below.

Print PDF Version

NON-PROFITS TAKE NOTE

You must submit a copy of your Ohio Tax Exempt form by USPS, fax, or seperate email before this application can be processed.

Section A - Company Information

Company Name

Owner/President Name

Date Inc.

How Long in Business

Is this, or Are you a

Are You Tax Exempt?

Yes

Fed I.D. or SSN/Lic #

Type of repayment

COD - cash on demand

Account - weekly billing, net 30 days

Email for Invoices

Section B - Contact Information

Physical Address

Mailing Address

City

State

Zip

Phone Number

Fax Number

Section C - Ownership Information

Name

Title

SSN

Phone Number

Address

City

State

Zip

Section D - Bank Reference

Bank Name

Account #

Bank Address

City

State

Zip

Contact Person

Phone Number

Section E - Supplier Reference

Three (3) Supplier References must be provided. If you need to submit more, complete this form, submit it, then contact Phillips Companies Directly.

Supplier #1

Supplier Name

Address

City

State

Zip

Phone Number

Fax Number

Supplier #2

Supplier Name

Address

City

State

Zip

Phone Number

Fax Number

Supplier #3

Supplier Name

Address

City

State

Zip

Phone Number

Fax Number

Read Agreement

By signing this application, I agree to pay all charges within 30 days of invoice date or at time of delivery for cash accounts, unless previous agreements have been made. I understand that all unpaid balances will be charged 2% per month service charges until paid in full. Furthermore, I give The Phillips Companies and it’s agents permission to use whatever means necessary to investigate my credit history, both personal and business (for AR accounts only). I also agree to have all tax exempt certificates submitted to Phillips prior to material delivery or services rendered.

Do you agree?

Yes

When you click the "Send" button you will be sending all the information from this page in an email to Phillips Companies. If your information is acceptable, an associate will contact you as soon as possible.