The Philos Group | New Customer Signup

Welcome! Please provide us with the information below so that we can sign you up as our customer and extend a purchase credit line for you. ANY QUESTIONS REGARDING THIS FORM, PLEASE CALL US AT (630) 924-8747:
1. COMPANY INFORMATION
Company Name
Other Trade Names Used
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Main Telephone
Fax Number
Federal Employer ID (EIN)
Sales Tax Exemption No.
Length of Time in Business (in years)
Business Type
- C-Corporation
- S-Corporation
- LLC
- Partnership

2. PRINCIPAL OFFICERS, PARTNERS AND OWNERS
Name Title

3. AUTHORIZED PURCHASING AGENTS
Name Title Telephone Email Address

4. SHIPPING ACCOUNTS
UPS:
Prefer to use:
- UPS
FedEx:
Prefer to use:
- FedEx

5. ACCOUNTS PAYABLE DEPARTMENT CONTACTS
Name Title Telephone Email Address

6. BANK REFERENCE
Bank Name
Address
Street Address Address Line 2 City State ZIP Code
Contact Person at Bank
Telephone
Email Address

7. TRADE REFERENCES
Vendor/Supplier Name
Account Number
Credit Limit
Address
Street Address Address Line 2 City State ZIP Code
Contact Name Title Telephone Email Address
Vendor/Supplier Name
Account Number
Credit Limit
Address
Street Address Address Line 2 City State ZIP Code
Contact Name Title Telephone Email Address
Vendor/Supplier Name
Account Number
Credit Limit
Address
Street Address Address Line 2 City State ZIP Code
Contact Name Title Telephone Email Address

8. ESTIMATED PURCHASE VOLUME FROM PHILOS
Average Monthly $ Volume
Estimate Total Yearly $ Volume
Credit Line Requested

9. AFFIDAVIT
The information and statements in this application are true and complete, and are made for the purpose of inducing you, to establish a line of credit. You are authorized to obtain any information you consider necessary from any source concerning the statements in this application.

In consideration of, and in order to induce you to establish a line of credit based on the foregoing application, the undersigned promises to pay for all purchases in accordance with your terms of sale. Said terms of sale being Net 30 days, normal procedure is to place accounts exceeding 60 days on C.O.D. If at any time, for any reason, the undersigned is unable to pay for said purchases when due, the undersigned agrees to pay and authorizes you to bill my/our account, interest, computed monthly at the legal rate of 12% per year (1% per month) on any past due amount (principal and interest) owing on my/our account. In the event it becomes necessary for your company to incur collection costs or institute suit to collect any amount due under this agreement or any portion thereof, the undersigned promises to pay such additional collection costs, charges and expenses including reasonable attorney’s fees if the account is placed in the hands of any attorney for collection.

The above Credit Application and following Statement of Terms & Conditions has been read and is agreed to by:
Authorized Officer Name
Title
Telephone
Email Address
Enter Email Confirm Email
Date
MM slash DD slash YYYY
Signature

Name	Title

Name	Title	Telephone	Email Address

Name	Title	Telephone	Email Address

Contact Name	Title	Telephone	Email Address

Step 1 of 9

1. COMPANY INFORMATION

2. PRINCIPAL OFFICERS, PARTNERS AND OWNERS

3. AUTHORIZED PURCHASING AGENTS

4. SHIPPING ACCOUNTS

5. ACCOUNTS PAYABLE DEPARTMENT CONTACTS

6. BANK REFERENCE

7. TRADE REFERENCES

8. ESTIMATED PURCHASE VOLUME FROM PHILOS

9. AFFIDAVIT