Quote & Credit Application

Applicant Information

Name *

First

Last

Title

Phone *

Fax

Email *

Bank Information

Bank Name:

Bank Address:

Address Line 1

Address Line 2

City

State

Zip Code

Bank Phone Number:

Type of Account(s) Held:

Savings Account Number:

Checking Account Number:

Other:

Insurance Information

Insurance Carrier:

Carrier Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number:

Fax Number:

Policy Number:

ICC Number:

Broker Name:

Type of Insurance:

Type of Liability:

Expiration Date:

Limits:

Self-Insured:

Yes
No

If yes, please provide letter on company letterhead. *

Click or drag a file to this area to upload.

Please upload your document here.

Tax Information

Are You Tax Exempt?

Yes
No

If “yes”, A signed and dated sales tax or resale exemption certificate is required *

Click or drag a file to this area to upload.

Please upload your document here.

Customer Affirmation: I (We) affirm that all the information given to Cooling Concepts is true and correct>. I (We) agree to notify you immediately of any changes in ownership. Cooling Concepts is authorized to conduct a credit survey and to obtain credit information from all sources deemed necessary. If credit is granted to me, I (We) agree to pay all of the invoices within 30 days from date of invoice. If payment is not made within 45 days, invoice is subject to finance charges. *

Yes, I (We) Agree

Your Name: *