Faulkner Haynes Credit Application

"*" indicates required fields

Address Information

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Shipping Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Info

Accounts Payable Contact Name*

(First & Last Name)

Accounts Payable Contact Phone*

Accounts Payable Email*

Email for Invoices*

Email for Statements

Business Info

Business Type*

Date Company Started*

Company Classification*

List Owners/Principals:

1. First & Last Name*

Title*

2. First & Last Name

Title

3. First & Last Name

Title

Trade References:

1. Company Name

Contact Name

2. Company Name

Contact Name

3. Company Name

Contact Name

Customer Portal:

Faulkner Haynes maintains an online Customer Portal that allows customers to track orders & shipments, as well as view/download invoices & statements. Please list anyone (not already listed above) who should have a login for the Customer Portal

1. Name

Title

2. Name

Title

3. Name

Title

Name of Faulkner Haynes Employee You’ve Been Working With*

Attach File(s) here:

Drop files here or

Max. file size: 16 MB.

Signature/Consent:

Name of Person Completing Application*

Title*

E-mail*

Consent*

I agree to the following terms:

By submitting this application, I agree to allow Faulkner Haynes to use the information provided for the purposes of determining whether to offer business credit to the company listed herein. Submission of this application does not guarantee credit approval. Additionally, I represent that I am authorized by the company listed herein to submit this application on its behalf.

This field is for validation purposes and should be left unchanged.

Faulkner Haynes Credit Application

Company Information

Address Information

Billing Info

Business Info

Products

Helpful Links

Contact