Please complete this form in its entirety. Submitting an incomplete form will cause delays in processing.

Legal entity (required)

DBA (if applicable)

Corp.LLCPartnershipSole proprietorship

Legal street address (required)

City (required)

State (required)

Zip (required)

Billing address (if different from above)

City

State of incorporation/organization

Zip

Subsidiary of

Division of

Are checks issued under a different name?
YesNo

Year started in business

Phone number (required)

Fax number

Your email (required)

Requested credit limit (required)

Estimated annual volume (required)
Mo.Yr.

Standard terms are net 30 with Chase Plastics unless otherwise negotiated.

Approval based upon credit review

President

Email

Phone Number (mobile)

Vice president

Email

Phone Number (mobile)

Purchasing contact

Email

Phone Number (mobile)

A/P mgr. or controller

Email

Phone Number (mobile)

State sales tax resale number

Please attach copy of certificate

Federal ID number

Dun & Bradstreet number

Accounts payable contact

Name (required)

Telephone number (required)

Ext.

Fax number

Email (required)

Please provide the best email address to send invoices: (required)

The undersigned hereby agrees that should a credit account be opened, in the event of default in payment of amount due, applicant agrees to pay any collection costs incurred during the collection process, which may include lawyer fees and maximum interest charges allowed by purchaser's state. All billing disputes must be reported by the customer within 10 days of receipt. The undersigned, as an inducement to grant credit, warrants that the information submitted is true and correct. Applicant has a continuing obligation to update the information provided and guarantee its accuracy. Applicant authorizes Chase Plastic Services to check all bank and other credit references of Applicant and disclose information regarding applicant's indebtness to any bank or other grantor of credit. It is agreed upon that the approved credit limit or terms may be withdrawn with or without prior notice upon default in payment. As an authorized representative of the company, I have acknowledged receipt of, read and accept Chase Plastic Services, Inc. "Conditions of Sale."

Digital signature (required)

Title (required)

Date YYYY-MM-DD format (ex. 2013-04-08) (required)

*A current application is required to be kept on file; if the application is dated 2 or more years, a new application may be requested for our records.

Please indicate what type of market your company sells to by using % amounts:
% % % % % % %
Auto Medical Industrial Construction Furniture Electrical Other

If other, explain:

Please either attach bank and trade references or list them below. Please include fax numbers.

Bank Information

Name (required)

Address (required)

Telephone number (required)

Fax number (required)

Trade references. Please list at least one resin supplier.

Supplier name

Account number

Telephone number

Fax number

Contact name

Contact email

Supplier name

Account number

Telephone number

Fax number

Contact name

Contact email

Supplier name

Account number

Telephone number

Fax number

Contact name

Contact email

Supplier name

Account number

Telephone number

Fax number

Contact name

Contact email

"ECOA" The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age; (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the consumer credit protection act. The federal agency that administers compliance with this law concerning this creditor is Federal Trade Commission, Equal Credit Opportunity; Washington, D.C. 20580

If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact Chase Plastic Services, 800-232-4273, within 60 days from the day you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement.