Frank Lowe Rubber & Gasket

Application for Open Account Billing

Fill Out Form Completely - Sign & Fax to: 631-777-2560

Name of Business:
Contact:
Street Address:
City:
State:
Zip Code:
Phone Number:

Corporation, Partnership, or Sole Proprietorship, Other:
Nature of Business or SIC/NAICS Code:
President:
CFO or Equivalent:
Accounts Payable Contact:
Materials Manager:
Purchasing Manager:
Purchasing Agent:
Engineering Manager:
Date Business Started:

Date Incorporated:

D & B Rating:
Total annual sales: $
Number of Employees:

Name of Bank:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Account Name:
Account Type:
Account Number:

REFERENCES (From who you buy on open account)

Refferences 1
Company Name:
Contact Person:
Account #:
Address:
City:
State:
Zip:
Phone #:
Fax #:

Refferences 2
Company Name:
Contact Person:
Account #:
Address:
City:
State:
Zip:
Phone #:
Fax #:

Refferences 3
Company Name:
Contact Person:
Account #:
Address:
City:
State:
Zip:
Phone #:
Fax #:

Should you approve this application, I (we) agree to pay for all goods purchased within the terms of 1% - 10 days: Net 30 days. FRANK LOWE RUBBER & GASKET CO., INC. is authorized to contact any references or bank listed above. It is understood that any information so obtained will be used solely for the purpose of granting credit.

Dated:

Completed By:
Title:

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Application for Open Account Billing