COMPANY INFORMATION
Customer Name
Phone
E-Mail Address
Street Address 1
Street Address 2
Mailing Address
City
State
Zip
Check one:	Corporation Partnership Proprietorship
State of Incorporation
Are you sales tax exempt?	Yes No
Type of Business
OWNER/OFFICER INFORMATION
Name
Title
Home Address
Phone
City
State
Zip
BANK INFORMATION
Bank Name
Account Number
Contact
Address
Phone
City
State
Zip
TRADE CREDIT REFERENCES - #1
Name
Acct. Number
Contact
Address
Phone No.
City
State
Zip
TRADE CREDIT REFERENCES - #2
Name
Acct. Number
Contact
Address
Phone No.
City
State
Zip
TRADE CREDIT REFERENCES - #3
Name
Acct. Number
Contact
Address
Phone No.
City
State
Zip
BILLING INFORMATION
Customer Name
Physical Address
Mailing Address
City
State
Zip
Attention
Telephone
Fax
Purchasing Contact
Purchasing Telephone
Fax
Purchase Order Number required	Yes No
No. of invoice copies required
Amount of credit requested	.. $
Accounts Payable Contact
A/P Telephone
A/P Fax
Tax Location
Taxable Status	Taxable Non-Taxable*
Comments:
SHIP TO INFORMATION
Customer Name
Attention
Address 1
Address 2
City
State
Zip Code
Special Shipping Instructions:
By submitting this form I certify that all the information provided is true and complete.
CREDIT AGREEMENT
Note: A copy of our credit agreement must be faxed to American Steam, Inc. Click here to complete this form.