Suburban Bolt - Fasteners, Tools, Abrasives

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Date: 11/23/2008

Company Information

I would like to have on-line ordering capability.
Desired Username:

- You will receive two emails; one confirming your user name and one containing your Suburban Bolt account number.

Your account number will be your password for your first login. You will then be prompted to select a new password.

*All Fields Required

COMPANY NAME:
LEGAL (if different):
Type of Business:
Years in Business:
Credit Requested:
Number of Employees:
Purchasing Manager:
Phone #:
Fax #:
Email:

BILLING Address

ADDRESS:
CITY:	STATE:	ZIP:
COUNTY:
PHONE:	FAX:

SHIPPING Address

ADDRESS:
CITY:	STATE:	ZIP:
PHONE:	FAX:

Type of
Organization

	Private Corporation		Partnership	Public Corporation
	Individual		Other

Principals

NAME	POSITION	ADDRESS	PHONE#

Bank Reference

Bank:		Account #:
Branch:		Contact Name:
Address:		Phone #:

Trade References

(Minimum of 3)

NAME	ADDRESS	PHONE #	FAX #

Special Company Information

Special comments to be
included on documents:

Area of Specialization:

Resale	Retail
Electrical/Mechanical	Construction
Machine Tool Builder	Tool & Die
Automotive
Other

How did you hear
about Suburban?

Salesperson	Internet	Walk-in
Yellow Pages	Referral
Other

Will you accept Back Orders?

Yes No

Will you accept Substitutes?

Yes No
Yes, only with approval

Which shipping method
will you use most often?

BESTWAY	PICKUP
UPS	OUR DELIVERY
UPS CONSIGNEE: your #

Do you always
require a PO#?

Yes No
If yes, is there a default PO#?
Experiation Date of default PO#

Any other notes or
special account requests:

In making this application for credit, the customer agrees to pay all invoices within 30 days from date of invoice. In the event a suit is necessary to collect any amount, the customer agrees to pay the seller's reasonable attorney fees and costs including attorney's fees for appeal.

Name: Title: Date:

ISO 9001:2000 REGISTERED
Certificate # 1106 Registration date: November 15, 1999

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