APLICACION DE CREDITO / FORMULARIO PERFIL COMERCIAL

Billing Address/ Direccin a donde le enviamos su factura:

TYPE OF BUSINESS

Business Name & DBA/Nombre de la Empresa

Street Address/Direccin Completa
City/Cuidad

State/Edo.

Telephone

Zip/CP

Country

Fax

CORPORATION
PARTNERSHIP
SOLE PROPRIETORSHIP
U.S. Fed ID # (EIN) __________________

Shipping Address (if different): Direccin (Si es Diferente)

Date Business Established_____________

Business Name & DBA Nombre de la Empresa

Date of Incorporation (if Inc.)____________

Street Address/ Direccin Completa

State of Incorporation (if Inc.)____________

City

State

Telephone

Zip

Are you the original owner? ______________

Country

Are you sales tax exempt?

Fax

certificate)

Freight Forwarder Address:

Name

(If yes, attach

Address

City/State/Zip

Telephone __________________ Fax __________________

Name of Principal Owner and Title: _____________________________________________________________________

Purchasing Contact:
Email or Fax No. ____________________ Is PO # required?_____
Accounts Payable Contact:
Email or Fax No.___________________
Website Address:

Products Distributed: __HVAC/R __Appliance __Tools __Instruments __Equipment __Other

Customer Channel Designation: __Retailer _OEM __Distributor/Wholesaler __More than/__Less than 5 Branches
Major Lines Distributed:_______________________________________________________________________________
COMMERCIAL REFERENCES
Dun & Bradstreet D-U-N-S # _________________________________________________
Name of Company
Address
Telephone ( )

Account Number
City/State
Fax ( )

Zip

Name of Company
Address
Telephone ( )

Account Number
City/State
Fax ( )

Zip

Name of Company
Address
Telephone ( )

Account Number
City/State
Fax ( )

Zip

Date

Authorized Signature

YOUR COOPERATION IN COMPLETING THIS APPLICATION ACCURATELY AND COMPLETELY WILL

ASSIST US IN PROCESSING THIS CREDIT REQUEST AS SOON AS POSSIBLE.
**Note: Your first Purchase Order must accompany this application and must meet the minimum dollar threshold.
Are you working with a LucasMilhaupt Sales Rep?

Name of Rep Miguel Harris

Lucas-Milhaupt, Inc. 5656 S. Pennsylvania Ave. Milwaukee, WI 35110 USA Phone: 414.769.6000 Fax: 414.769.1093 www.lucasmilhaupt.com