Credit Application

"*" indicates required fields

Mercer Agent/ Sales Person*

Contact Information

Legal Name of Business*

DBA Name

Date of Incorporation

State of Incorporation

Officer Name

Officer Title

Officer Phone

Officer Email

Address

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

A/P Contact

A/P E-mail

A/P Phone

A/P Fax

Type of Entity

Type of Business

Years in Business

Federal ID#

D & B #

No. of Employees

Annual Revenue

Freight Billing Address

Same as above

Billing Company Name

Billing Address

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

Billing Contact

Billing Email

Billing Phone

Billing Fax

Email for Sending Invoices

Banking and Credit References

Bank Information

Bank Name

Bank Address

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

Bank Contact

Years of Relationship

Bank Phone

Bank Email

Account #

Trade Reference 1

Creditor Name

Creditor Address

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

Creditor Contact

Years of Relationship

Creditor Phone

Creditor Email

Trade Reference 2

Creditor Name

Creditor Address

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

Creditor Contact

Years of Relationship

Creditor Phone

Creditor Email

Upload Documents

Drop files here or

Max. file size: 100 MB.

Upload your W9, Surety Bond (if broker), Credit Packet and any billing instructions here

Authorized Signature*

Title

This field is hidden when viewing the form

Date

For questions about credit or problems with this application, please contact Jeff Meade at 502-625-3177 or at [email protected]

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Mercer Online Credit Application

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