Credit Application

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5860 Paramount Blvd., Long Beach, CA 90805
Tel: 562-602-3797 Fax: 562-602-3726
Confidential Credit Application (New / Update Account)

We welcome your interest in doing business with TA Chen Int'l. The extent to which this application is completed will assist us in determining the extend of a line of credit to your organization. All information submitted will be held in strict confidence and used solely for reference purpose within our company.

Customer Type: *

New

Re-activate

Past Customer Account #:

Legal Business Name: *

DBA:

Phone: * {{ errorMsg.required }}

FAX: * {{ errorMsg.required }}

Bill To Address:

Address1: * {{ errorMsg.required }}

Address2:

Country: * {{ errorMsg.required }}

City: * {{ errorMsg.required }}

State: * {{ errorMsg.required }} {{ errorMsg.required }}

Zip: * {{ errorMsg.required }}

Ship To Address:

the same as billing address above

Address1: * {{ errorMsg.required }}

Address2:

Country: * {{ errorMsg.required }}

City: * {{ errorMsg.required }}

State: * {{ errorMsg.required }} {{ errorMsg.required }}

Zip: * {{ errorMsg.required }}

Business Information

Applying Credit Limit:

UPS Account:

UPS ZipCode:

Refer from Brighton-Best Int'l: *

Yes

Have you been in contact with any TA CHEN salesperson: *

Yes

If Yes, salesperson name:

Business Type: *

If corporation, which year incorporated:

If corporation, which state incorporated:

SIC Code:

Related Companies:

Relationship:

Year established: *

Under present ownership since:

How many employees: *

Estimated annual sales:

Type of products on carrying:

Type of material purchased:

How did you find out about TA CHEN Int'l:

Federal TAX ID: *

*(Must provide photo copy of federal tax id)

Resales ID: *

*(Must provide photo copy of resales id)

Check here if your company resides at state which exempt from providing resale certificate

Dun & Bradstreet No:

Owner/Officer:

Full Name: *

TEL: *

FAX: *

E-Mail: *

Paperless Billing Primary Contact:

First Name:

Last Name:

Title:

E-Mail: {{ errors.first('primary_contact_email') }}

Back-up Contact:

First Name:

Last Name:

Title:

E-Mail: {{ errors.first('backUp_contact_email') }}

Check here if you will fax your own sheet of trade and bank reference lists

Trade Reference:

*(At least three from whom purchases are made on a direct credit basis)

Name: * {{ errorMsg.required }} {{ errorMsg.required }} {{ errorMsg.required }}

Telephone: * {{ errorMsg.required }} {{ errorMsg.required }} {{ errorMsg.required }}

Fax: * {{ errorMsg.required }} {{ errorMsg.required }} {{ errorMsg.required }}

Bank References (must sign and fax the authorization section below)

Bank Name: * {{ errorMsg.required }}

Title: * {{ errorMsg.required }}

Contact Name: * {{ errorMsg.required }}

Account Number: * {{ errorMsg.required }}

Phone: * {{ errorMsg.required }}

Fax: * {{ errorMsg.required }}

Your Information:

the same as owner/officer above

Your Name: *

Your E-Mail: *

send me a copy of this report by e-mail

I HAVE READ, UNDERSTAND AND ACCEPT THE ABOVE TERMS AND HAVE PROVIDED TRUE INFORMATION TO THE BEST OF MY KNOWLEDGE. I FURTHER AUTHORIZE TA CHEN INT'L TO VERIFY ANY AND/ OR ALL REFERENCES GIVEN THAT MAY BE REQUIRED TO DETERMINE OUR CREDIT CAPABILITIES AND TO REQUEST RELEVANT INFORMATION FROM CREDIT REPORT AGENCIES. THIS AGREEMENT WAS MADE IN LONG BEACH, CA AND ANY DISPUTE OR LITIGATION RESULTING FROM THESE TRANSACTIONS WILL BE FILED IN THIS JURISDICTION. SHOULD IT BE NECESSARY TO REFER THE ACCOUNT BALANCE TO A LICENSED COLLECTION AGENCY OR ATTORNEY FOR LEGAL ACTION, APPLICANT AGREES TO PAY A 25% COLLECTION FEE, REASONABLE ATTORNEY FEES AND COURT COSTS.