Credit Application and Agreement

Company Information

Full Name of Company:

Mailing Address:

City:

State:

Zip:

Street Address (if different):

Office(s):

Fax (if applicable):

Business Type:

Corporation

Partnership

Sole Proprietorship

Limited Partnership

Federal Tax ID No or SSN:

Do you require a W-9 to process our payment?

Yes

No

A/P Contact:

Phone Number:

Email:

Bank References

Bank:

Address:

Phone Number:

Account Number

Contact:

Credit/Trade Reference 1

Name:

Address:

Phone Number:

Fax Number:

Credit/Trade Reference 2

Name:

Address:

Phone Number:

Fax Number:

Credit/Trade Reference 3

Name:

Address:

Phone Number:

Fax Number:

Sales Agreement

All invoices are due 30 days from date of invoice.
A Periodic Finance Charge (annual percentage rate of 24% or 2% per month) will be applied to any past due balance. Customer will be responsible for any and all collection fees incurred.
By submitting this application, you authorize Murphy Asphalt and Construction to make inquiries into the banking and business/trade references you have supplied.
All Terms are subject to change based on credit pay/credit history.

Name:

Date:

Title:

Verify

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