Please fax the completed new account request form

Notes for completing application & our review process:
Approving a new account will typically take up to 3 business days. When you submit a new account
request, Cementcore must fax a request for credit information to each of the references you provide.
You can help speed up the process by following these helpful hints:
1. If you are tax exempt, please provide us a copy of your Tax Exemption Certificate. All orders without
a valid TEC will be subject to applicable tax.
2. It is common for references to disregard our requests. Please sign the attached trade release form and
check with your credit references periodically to make sure that they actually respond for
credit information.
3. Because we must fax your credit reference a form to complete, you will want to make sure that you provide the correct phone and fax number for all of your references. Although we will attempt to
follow up by phone if we do not hear back from your references, there could be a delay of several days.
4. We will need a minimum of (1) Bank Reference and (2) Trade References.
5. The attached form must be fully completed, signed and returned before your request for an account can be considered.
Please fax the completed new account request form
and references to 866-465-0306.
Please call 844-880-6020 for questions regarding Cementcore.
Customer Account Request Form
Please complete, sign and return this form along with
any additional documentation
Purpose
New Account/Customer
Website: cementcore.com
Phone: 844.400.2589
Update an Existing Account
Billing Address
Legal Name / Parent Company
Trade Name / DBA
Tax ID
Industry Number
Duns & Bradstreet #
Street Address
Website URL:
City
State
Zip Code
County
Shipping Address
Name
Street Address
City
State
Zip Code
Contact Information
Accounts Payable
Email
Phone Number
Purchasing Agent
Email
Phone Number
Receiving Contact
Email
Phone Number
Business Leader / Title
Email
Phone Number
Sales Tax Status
Taxable
Tax Exempt ¹
Years in Business
0-5 years
6-10 years
Company Composition
Corporation
LLC
11-15 years
More than 15 years
Partnership
Sole Proprietorship
Type
Hospital
Government
International
Distributor ²
Education
3rd Party Repair
Other
Warehouse/Central Distribution Ctr
Reseller ²
Nursing Homes
Private/Individual Sale
Revenue range over last five years
Less then USD 1 Million
USD 1 to 10 Million
USD 10 to 50 Million
More than USD 50 Million
Bank Reference
Name
Fax
Street Address
Phone
City
Type of Account
State
Checking #
Zip Code
Saving #
Loan #
Trade Reference 1
Name
Fax
Street Address
Phone
City
State
Zip Code
Trade Reference 2
Name
Fax
Street Address
Phone
City
State
Zip Code
2
Person 1
Person 2
Person 3
Name
Nationality
Date of Birth
Tax ID or SSN
Address
Phone
Percent of Ownership
Did the listed person(s) hold director, officer or other management
positions with companies or entities?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If Yes Company
Title
A. Is the listed person(s) a current official or employee, including
any government owned or controlled enterprise or international
organization?
B. Is the listed person(s) involved in any business relationship
(including acting as an agent or consultant for or holding common
ownership of any business enterprise or partnership) with any current
official (or close family member) or employee of the government,
including any government ministry, agency or government-owned or
controlled enterprise?
If answer to A or B is Yes, please provide below details:
Full name of government, company or party Position
Official responsibilities
For relatives, the relationship
For common business interest, the type of business relationship,
including the name of any enterprise or partnership and the nature of
any agency agreement
I understand that payment is due 30 days after invoicing and agree to abide by these terms. Failure to abide by these terms may result in delayed orders, interest charges or cash in advance
basis. No exceptions will be made unless they are set forth in writing and signed by an authorized agent of Cementcore. The undersigned certifies that the information is true and correct,
and authorizes Cementcore to complete a credit investigation from the references that have been supplied. Authorization for terms by one division does not guarantee terms granted by all
divisions.
Printed Name
Title
Signed Name
Date signed
¹ A photo copy of a valid tax exempt certificate must be provided before the application is processed
² The Ownership and Management/Government relationships section must be completed
Bank Account Information Release Form
Date
Bank
Attention
Company Name
Street
CityStateZip Code
Phone #Fax #E-mail
Bank account numberCheckingSaving
it is understood that by signing this form the above named company gives permission for its bank account
Printed NameTitle
SignatureDate
Trade Reference Release Form
The following information is submitted by Cementcore for consideration as a basis for the extension of credit.
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