Customer Credit Application

After completing the form, click "Submit" to send you application directly to our processing team. You also have the option of selecting "Print Form" which will produce a pdf version of your application which you can keep for your records.
Bill To Ship To
Legal Company Name
Street Address
City, State
Zip Code +4
Phone#
Fax#
Accounts Payable Contact
Email Address
Business Type (please check one)
Are you Tax Exempt? - YES/NO (if yes, please fax us your tax exempt form 1-808-949-2209)
Tax ID#
Name and Contact Information of Principals/Owners
Name: Title: Tel:
Name: Title: Tel:
Name: Title: Tel:
References
Bank Trade
Bank Name: Company:
Bank Phone Number: Company Phone:
Bank Fax: Company Email:
Contact Name: Company Fax:
Bank Address: Contact Person:
Bank Email: Company Address:
Trade Trade
Company: Company:
Company Phone: Company Phone:
Company Email: Company Email:
Company Fax: Company Fax:
Contact Person: Contact Person:
Company Address: Company Address:

By signing this application, the above named applicant approves release of credit information to CBI Polymers, Inc., for the purpose of assessment of credit and collection of debt.

Conditions and terms: In consideration for credit being extended, I or we agree to the following: (1) Payment is jointly, severally and unconditionally guaranteed within 30 days of date of delivery; (2) any charges unpaid after the above 30 days are to be increased 1 1⁄2% per month; (3) any charges still outstanding after 90 days from the date of delivery are subject to collection, and all reasonable collection related expenses; (4) all claims, requests for adjustments or notifications of errors must be made within 30 days of the date of the invoice or charges are conside red accepted; (5) credit privileges may be withdrawn at any time without invalidating the terms of this agreement.

Authorized Signature
Date
Title
Telephone

Please email completed form and direct questions to: orders@decongel.com