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Instructions: click here to view/print instructions
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Corporation or Business Name: |
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If different from above,
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DBA or Trade Name: |
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Billing Address: |
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Street/PO Box: |
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City: |
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State: |
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ZIP Code: |
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Use the "Copy Address" button below to copy the Billing Address to the Physcial Address.
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Physical Address: |
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Street: |
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City: |
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State: |
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ZIP Code: |
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Business Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Federal ID#: |
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State of Organization: |
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Business Structure: |
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Name of Owner or President:
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First Name: |
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Middle Name/Initial: |
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Last Name: |
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Suffix: |
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Year Company Established: |
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Current Ownership Since: |
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Company's Annual Revenue: |
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Are you in the equipment rental business?
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Rental House: |
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Nature of Business: |
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Bankrupty Ever Filed: |
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If YES, Date Filed: |
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Are there any outstanding liens or judgements?
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Outstanding Liens or Judgements: |
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If YES, Dollar Amount: |
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Credit Line Requested: |
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Tax Exempt: |
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If YES, attach exemption certificate.
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Purchase Orders Required: |
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Accounts Payable Contact:
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First Name: |
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Last Name: |
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Email Address: |
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If you accept invoices or statements via email, enter the email addresses.
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Invoice Email Address: |
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Statement Email Address: |
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Name of Bank: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Checking Account #: |
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Loan #: |
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Name of Bank: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Checking Account #: |
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Loan #: |
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Complete if you have financed equipment within the last 24 months.
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Equipment Financing Company: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Account # / Loan #: |
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Equipment Financing Company: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Account # / Loan #: |
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Supplier: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Products Supplied: |
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Supplier: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Products Supplied: |
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Supplier: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Products Supplied: |
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Supplier: |
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Area Code / Phone Number: |
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Fax Area Code / Phone Number: |
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Products Supplied: |
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Please provide the following optional information. This data is used to better serve our customers.
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Number of Employees: |
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Full time mechanics employed?
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Full Time Mechanics: |
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Do you operate your own service shop?
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Service Shop: |
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Applicant hereby authorizes Anderson Equipment Company and Anderson Equipment Company (NY), Inc. (collectively "Anderson"), its affiliates or its assignee(s) to obtain information from any source including credit reporting agencies and hereby authorizes the above named bank(s), financial institutions(s) or trade references(s) to release such information as necessary to establish credit, financing or leasing arrangements with the above mentioned parties. This authorization shall remain in force so long as Applicant has a line of credit with Anderson and Anderson reserves the right to periodically update its information from any source. The undersigned agrees that payment will be made for all purchases in accordance with the terms of sale. The undersigned agrees to pay the prevailing service charge on account balances not paid according to the terms of sale. Anderson's terms of sale supersede any and all purchase orders presented by Applicant unless Anderson has agreed in writing to alternative terms and conditions. In the event that this account is referred for collection, the undersigned agrees to pay all expenses, including reasonable attorney fees, incurred in connection with such collection as stipulated in Anderson's terms of sale. The undersigned hereby represents that all information contained in this Credit Application is true, correct and complete, and is provided for the purpose of obtaining credit in an amount set by Anderson's credit policies and procedures. A Photostat, digitized or facsimile copy of this authorization shall be valid as the original.
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2015.07
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The Applicant Name, Title, and Email Address entries must be for the individual who is going to sign the Credit Application.
The Applicant Email Address entry is only required if the Electronic Signature entry below is YES.
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Applicant:
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First Name: |
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Middle Name/Initial: |
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Last Name: |
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Suffix: |
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Title: |
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Email Address: |
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After Submit, do you want to electronically sign the Credit Application using Adobe EchoSign?
If YES is selected, after Submit the Credit Application will be emailed by Adobe EchoSign to the Applicant Email Address specified above.
If NO is selected, after Submit you must print the Credit Application (using the link provided after the Submit has been completed), then forward a signed copy to Anderson by email, mail, or fax.
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Electronic Signature: |
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Submit forwards the Credit Application to our Credit department.
Once submitted, you will no longer be able to change this Credit Application, so please review all information before submitting!
To be eligible for submission, all required entries () & any applicable conditional entries () must be filled in.
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