Open An Account

Credit Application

Please fill out this form and click submit to send the information directly to Charleston Rubber & Gasket's accounting team.

Business Name

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Person Completing This Application

First Name

Last Name

Phone

(###)

###

####

Accounts Payable Contact

First Name

Last Name

Phone 1

(###)

###

####

Date Business Established

YYYY

Business Type

Tax Exempt?

Are Purchase Orders Required?

Are Monthly Statements Required?

Preferred Invoice Delivery

Accounts Payable E-Mail

Any Special Requirements?

Trade Reference 1

Include business name, location, phone, fax and email please.

Trade Reference 2

Include business name, location, phone, fax and email please.

Trade Reference 3

Include business name, location, phone, fax and email please.

Digital Signature & Authorization

TERMS AND CONDITIONS 1. Terms are Net 30 days, unless otherwise approved in writing. 2. No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department. 3. Account holder will be responsible for any and all collection or attorney fees necessary to collect payment of charges on this account. In completing below, I acknowledge, accept and agree to the above terms and conditions. I verify that all information provided on the credit application is true and correct. I authorize Charleston Rubber & Gasket to investigate the references provided as to substantiate our company’s financial responsibility.

print credit application

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Click to download and print credit application