10950 Linpage Place St. Louis, MO 63132 PH: 314-241-1214 FX: 314-241-2277 www.hy-c.com
CUSTOMER APPLICATION North America International
Section 1: General Information Customer Name:
Phone:
Physical Address:
Email:
City & State
Postal Code
Fax:
Website:
Mailing Address same as physical address Different (enter address below)
City & State
Postal Code
Facebook/Social Media
Shipping Address: same as physical address Different (enter address below)
Membership in Buying Groups? YES NO
City & State
Postal Code
Group Name:
# of Employees:
SIC Code:
DUNS number:
State of Incorporation:
Date Business Started
Sales Tax Exempt? Yes FEIN # or VAT #
No
Type of Business:
Individual
Partnership
LLC
S-Corp
C-Corp
Other: _____________
If Subsidiary, Name & Address of Parent Company:
Please list any other company names that you have been associated with a HY-C Account:
Company Contact Information
(Please list the appropriate contact person for the following activities)
Communication (method)
Contact Name
Email Address
Phone #/Ext.
Order Confirmations (email)
Invoices (email)
Accounts Payable (email/phone)
Shipping Notices (email)
Sales
Purchasing
Marketing/COOP
YES NO
Drop-Ship Account? YES NO
Back-Orders Allowed: YES NO
Warehouse Account?
Account Set-Up Information (HYC USE ONLY)
Customer Class
Terms of Sale:
Sales Representative:
WAREHOUSE ACCT. #:
DROP-SHIP ACCT #:
Cust Type/Tier:
Freight Terms:
PPD & ADD
FOB St. Louis
PPD on Cust Account
Other:
Credit Limit:
Approved by:
Date:
10950 Linpage Place St. Louis, MO 63132 PH: 314-241-1214 FX: 314-241-2277 www.hy-c.com
Section 2: Line of Credit Request
Requested Credit limit:
Requesting Credit line? No (skip this page) Yes (fill out this page)
Please provide references which meet the following criteria: • Applicant is currently doing business with or has done business within the last three (3) years. • Credit lines similar to the $ volume as requested with this application. • Do NOT submit references that applicant does NOT want HY-C to notify of Application for Account. • Accurate information will expedite the processing of your application . Please verify contact #’s & email addresses. Applicants may elect to contact the Supplier to encourage their response in a timely manner. Bank Reference Bank Name Name of Officer/Contact:
Street Address:
Email Address:
Mailing Address: (if different)
Phone #:
Fax #:
City, State
Postal Code
Account Type:
Account #:
Supplier Reference #1
Company Name
Name of Contact
Street Address:
Email Address:
Mailing Address: (if different)
Phone #:
Fax #:
City, State
Postal Code
Account #:
Supplier Reference #2
Company Name
Name of Contact
Street Address:
Email Address:
Mailing Address: (if different)
Phone #:
Fax #:
City, State
Postal Code
Account #:
Supplier Reference #3
Company Name
Name of Contact
Street Address:
Email Address:
Mailing Address: (if different)
Phone #:
Fax #:
City, State
Postal Code
Account #:
10950 Linpage Place St. Louis, MO 63132 PH: 314-241-1214 FX: 314-241-2277 www.hy-c.com
Section 3: Principals/Officers Responsible for Commercial Transactions
Owner/Shareholder #1
Name
Title:
Social Sec. #:
% of Ownership
Street Address:
City, State
Postal Code
In consideration of HY-C Company LLC extending credit, I/we jointly and severally do personally guarantee unconditionally to HY-C Company LLC the payment of indebtedness of the within named firm
Signature: _________________________________________________________________________ Date: _____________
Owner/Shareholder #2
Name
Title:
Social Sec. #:
% of Ownership
Street Address:
City, State
Postal Code
In consideration of HY-C Company LLC extending credit, I/we jointly and severally do personally guarantee unconditionally to HY-C Company LLC the payment of indebtedness of the within named firm
Signature: _________________________________________________________________________ Date: _____________
Owner/Shareholder #3
Name
Title:
Social Sec. #:
% of Ownership
Street Address:
City, State
Postal Code
In consideration of HY-C Company LLC extending credit, I/we jointly and severally do personally guarantee unconditionally to HY-C Company LLC the payment of indebtedness of the within named firm
Signature: _________________________________________________________________________ Date: _____________
Please duplicate page if there are more than three (3) Owner/Shareholders
10950 Linpage Place St. Louis, MO 63132 PH: 314-241-1214 FX: 314-241-2277 www.hy-c.com
Section 4: Sales Tax
Required Action: Check the applicable box and follow instructions
I am NOT Sales Tax Exempt (HY-C will collect sales and/or use taxes on your purchases)
I am Sales Tax Exempt (Either use the link below or submit required certificates to HY-C with your completed account application)
By law, HY-C is required to collect sales and/or use taxes on your purchases unless provided with current valid exemption certificates for the states where your company’s purchases are shipped. HY -C uses Avalara's CertExpress to securely collect digital exemption certificates from our customers. To get started, please go to this link:
https://app.certexpress.com/?c=7255695653337154354a78445974636f6c6e453d:1918d1194a60ae195fceb084301 d8aba
You may also email the requested certificates with your completed Account Application.
10950 Linpage Place St. Louis, MO 63132 PH: 314-241-1214 FX: 314-241-2277 www.hy-c.com
AUTHORIZATION TO RELEASE BANK INFORMATION
By signing this Authorization, Applicant is agreeing to allow HY-C to solicit credit information for the purposes of determining the credit worthiness of A pplicant’s business in establishing open credit terms. By signing below, Applicant authorizes financial institution to release information concerning your account.
I, _______________________________________ (applicant name) of ____________________________ (company name),
hereby authorize ______________________________(credit institution) to release requested information
concerning my account and credit to the HY-C Company, Inc. of St. Louis, Missouri.
Account #:
Signed:
Printed Name:
Date:
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