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Fitz Chem Corporation
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Application for Credit

Please complete this form online and press the submit button or you may print this form and mail, email or fax it to:

  FITZ CHEM CORPORATION
450 E. Devon Suite 175
Itasca, IL 60143
FAX: (630) 467-1183
EMAIL: accounting@fitzchem.com

Fitz Chem Lockbox Remit to Address
6340 Reliable Parkway
Chicago, IL  60686

You may also download this form in Adobe Acrobat format: Credit Application Form
Contact Information
Name :
Email :
Phone :
Billing Address
Legal Name :
DBA/Trade Name :
Address/P.O. Box :
City, State, Zip :
Telephone :
Ship To Address
Company Name :
Address :
City, State, Zip :
Fax :
Company Information
Legal Entity : Corporation
Partnership
Proprietorship
Other
Date Established :
Years at Present Address :
Number of Employees :
D&B Rating:
Requesting Credit Line Amount :
(If you are requesting over $25,000 credit line, we require a copy of your most recent financial statement)
Net Terms : 30 DAYS
SIC Code :
Authorized Purchasing Agent/Buyers
Main Name:
Title:
E-Mail:
   
Secondary Name:
Title:
E-Mail:
Controllers/Accounts Payable
Main Name:
Title:
E-Mail:
   
Secondary Name:
Title:
E-Mail:
Bank Information
Bank Name:
Account Number:
Date Opened:
Telephone:
Contact:
Average Balance $:
Trade References
Company Name:
Address:
City, State, Zip:
Contact:
Telephone:
Fax:
   
Company Name:
Address:
City, State, Zip:
Contact:
Telephone:
Fax:
   
Company Name:
Address:
City, State, Zip:
Contact:
Telephone:
Fax:
  Please make sure to also complete the attached sales tax exempt form.
Due to state tax requirements we are required to have this form before
your order can ship.

A copy of your Registration Certificate does not satisfy the requirements.
ILLINOIS RESALE CERTIFICATE
SELLER
Name: Fitz Chem Corporation
Address: 450 E. Devon Suite 175, Itasca, IL 60143
PURCHASER
Name:
Address:

Purchaser hereby certifies that is engaged in the business of selling (description of property or service) and that the tangible personal property described herein which it will purchase from Seller will be purchased for the purpose of resale in the regular course of business, unless otherwise specified on each purchase order, and that the certificate shall remain in effect until revoked in writing.
DESCRIPTION OF PROPERTY PURCHASED
Complete (A) or (B)
A Purchaser holds a valid Illinois (registration/resale) issued pursuant to the Illinois Retailers' Occupation Tax Act.
   
B Purchaser hold the vallad registration No. issued pursuant to the Sales and Use Tax Law of the State of and it will always resale and deliver the above described property to its customers outside Illinois.
   
C Purchaser is subject to sales tax and agrees to pay sales tax on all invoices.

In the event that any of the above described property is used for any purpose other than resale, retention, demonstration, or display while holding the tax required by the Illinois Retailers' Occupation Tax and Use Tax Act. If the claimed exemption is denied by state taxing authorities, Purchaser agrees to reimburse Seller for any tax, interest, and penalties for which Seller is liable as a result of the denied exemption.

I swear or affirm that I have examined this certificate and that the information on it is true and correct (to the best to my knowledge and belief).

The undersigned hereby certifies that the information herein is true and correct. It is agreed and understood that the undersigned is an authorized agent of the applicant and is duly empowered to enter and make binding agreements on its behalf. Fitz Chem Corporation is hereby authorized to verify this information. Terms of sales are governed solely by the distributor agreement and Fitz Chem Corporation's sales invoice.

Name:
Title:
For Company:
Date: