Form - Credit Application | Roadrock Recycling

LOCATION

303 Hwy 93 N
Scott, Louisiana

2416 E. Hwy 90
New Iberia, Louisiana 70560

2899 Parham Rd.
Westlake, Louisiana 70560

7929 River Rd.
Baton Rouge, Louisiana 70560

Call the office anytime between the hours of 8:00AM - 12:00PM and 1:00PM to 5:00PM Monday-Friday

Roadrock Recycles!

© Jegtheme 2013. All Rights Reserved.

Form – Credit Application

by team@eighthats.com, November 23, 2015

Credit Application

Date*
MM slash DD slash YYYY
Company Name*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Physical Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Type of Business*
How long has your company been in business?*
Company is a*
- Corporation
- Partnership
- Sole Proprietor
Company Representative*
First Last
Company Representative Title
Contact Person in Billing/Accounts Payable
Is a Purchase Order Number Required?*
- Yes
- No
Is Company Tax Exempt?*
- Yes
- No
Tax Certificate
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 128 MB.
If company is Tax Exempt, must attach Tax Certificate.
Name of Company's Bank*
Bank Officer
Account Number
Bank Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Phone Number
Amount of Credit Requested
TERMS ARE NET 30
Trade References
Trade Reference Name #1
First Last
Trade Reference Phone #1
Trade Reference Address #1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Trade Reference Name #2
First Last
Trade Reference Phone #2
Trade Reference Address #2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Trade Reference Name #3
First Last
Trade Reference Phone #3
Trade Reference Address #3
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
We understand that this information is provided for the purpose of obtaining credit with JTD Services, Inc. and or Roadrock Recycling Inc. We certify that this information is accurate and true. We authorize JTD Services/Roadrock to investigate our credit worthiness, credit history, and financial responsibility. We also accept JTD/Roadrock's stated terms of 30 days and agree to pay in full in accordance with these terms, otherwise the amount due will be subject to 1 1/2 % interest per month until paid.
Name*
First Last
Date*
MM slash DD slash YYYY
Title*
Signature*