Welcome to Reliance

Company Name:*

DUNS#:

Website:

Address:*

City:*

State:*

Zip Code:*

Shipping Address (if different):

City:

State:

Zip Code:

Billing Address (if different):

City:

State:

Zip Code:

Purchasing Contact:*

Title:*

Phone #:*

Email Address:*

Accounts Payable Contact:*

Phone #:*

Fax #:

Email Address:*

Back Orders Allowed?*

YES NO

P.O. Required?*

YES NO

Is Reliance Supply, Inc. Authorized to charge Credit Card provided?*

YES NO

Invoices sent by:*

Email

Type of business:*

Corporation Partnership Individual LLC Sole Proprietorship Other

Years in business:*

Resale Tax Exempt Certificate #:*

Disclaimer: If the certificate is not provided,you will be charged sales tax for following states:Florida,Georgia,South Carolina,& Illinois

Attach copy of certificate:*

Bank Name:*

Phone #:*

Fax #:

Address:*

City:*

State:*

Zip Code:*

Account #:*

Contact:*

Title:*

Company #1 Name:*

Account #:*

Address:*

City:*

State:*

Zip Code:*

Contact:*

Title:*

Phone #:*

Fax #:

Company #2 Name:*

Account #:*

Address:*

City:*

State:*

Zip Code:*

Contact:*

Title:*

Phone #:*

Fax #:

Company #3 Name:*

Account #:*

Address:*

City:*

State:*

Zip Code:*

Contact:*

Title:*

Phone #:*

Fax #:

I (We) agree that,

Pending approval of this application, I (We) agree to pay for all goods and services purchased within thirty (30) days following he date of the invoice. Reliance Supply, Inc. is authorized to contact the references and / or bank listed above. Should it become necessary to collect this account by legal proceedings or other means, the undersigned, including endorsers, promise to pay all collection costs including reasonable attorney fees

Authorized Buyer / Officer:*

Title:*

Dated:*

21-Nov-2024

Welcome to Reliance!

We Need A Few More Items Answered to Enroll Your Company In Our System So We Can Deliver The Highest Level of Service

If you are requesting a Credit Account, please provide the below information.

Bank Information:

Trade References (List 3):

Products

Information