Wolberg Electrical Supply Company

Please fill out the fields below for processing by our credit department. We will contact you shortly with information about your account.

To download this credit application as a PDF document, please click here.

Basic Information

	Company Name:
	Physical Address:
	City:
	State:
	Zip:
	Mailing Address:
	City:
	State:
	Zip:
	Telephone:
	Fax:
	Type of Organization:		Corporation Individual Partnership LLC
	Federal ID:
	Tax Status - Exempt: (If yes, please provide exempt certificate.)		Yes No

Principal Owners or Officers

	*Owner #1*	*Owner #2*
Name:
Title:
Email:
Home Address:
City:
State, ZIP:
Type of Business:
Accounts Payable Manager:
Email:
Purchasing Agent:
Email:

Business References

	Company Name #1:
	Contact:
	Address:
	City:
	State:
	Zip:
	Telephone:
	Fax:

	Company Name #2:
	Contact:
	Address:
	City:
	State:
	Zip:
	Telephone:
	Fax:

	Company Name #3:
	Contact:
	Address:
	City:
	State:
	Zip:
	Telephone:
	Fax:

Bank References

	Bank Name:
	Contact:
	Address:
	City:
	State:
	Zip:
	Telephone:
	Fax:
	Account #:

If this account is placed in the hands of a bonded collection agency or attorney for collection, the undersigned shall pay an amount equal to 30% of the unpaid principle and interest as a collection fee, which amount the undersigned agrees is reasonable.

This is to certify that I am a principal in the above named business and in consideration for the extension of credit, I do personally guarantee payment of any and all invoices which remain unpaid and if the application for credit is a corporation, the undersigned, in addition to personally guaranteeing payment, represents that he/she/they are authorized to make this application on behalf of the aforementioned corporation.

	Printed Name:
	Title:
	Email: