HY-C Sales Partner Application

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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