Commercial Credit Application – Chipurnoi Candy®

To avoid any delay in processing complete in full. You may save your progress at anytime using the link at the bottom. The form will not be submitted until the submit button is clicked.

All information will be held in confidence.

Terms of Credit: First order is check OR charge card. Our terms are NET 20 days. We ship invoice to invoice.

ALL FIELDS REQUIRED FOR SUBMISSION
BILL TO:
Name*
First Last
Attn:*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Phone*
SHIP TO:
Name*
First Last
Attn:*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Phone*
GENERAL BUSINESS INFORMATION
Business Name:*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Type of Business*
Years in Business*
Fed ID#:*
Owner's Name*
Officer's Name*
Title*
Are you Sales and/or Use Tax Exempt?*
D.B.A.*
Accounts Payable Contact Name*
First Last
Accounts Payable Contact Phone*
BANK REFERENCE
Bank Name*
Address*
City State ZIP Code
Email*
Account Manager*
First Last
Phone*
Checking Acct #*
Savings Acct #*
Other
BUSINESS CREDIT REFERENCE (LIST MINIMUM OF THREE)
Reference 1
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Reference 2
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Reference 3
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Reference 4
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
APPLICATION FILLED OUT BY
Name*
First Last
Title*
Email*
Consent*
I agree
By submitting this application you authorize Chipurnoi Inc. to make enquiries to the banking, savings, business, and/or trade references you have supplied.

We certify that all the information on this form is correct and that we fully understand your credit terms and agree to the proper payment in consideration of extended credit.
Notes or Message
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BILL TO:

SHIP TO:

GENERAL BUSINESS INFORMATION

BANK REFERENCE

BUSINESS CREDIT REFERENCE (LIST MINIMUM OF THREE)

APPLICATION FILLED OUT BY