Weld Direct Corporation
Application for Credit

Company Name:   

Billing Address:    
         Billing City: St: AL AK AZ AK AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO NE NV NH NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY   Zip: 

Ship to Address:
         Ship to City:  St:  AL AK AZ AK AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO NE NV NH NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY   Zip:

Telephone:                 Fax:    

Type of Business:    Corporation Partnership Other Sole Proprietorship         Fed ID:
How long in Business: Duns #
Accounts Payable Contact: Phone: Ext:

Bank References:
Name:     Contact:    Phone:
Fax:     Account #

Name:     Contact:    Phone:
Fax:     Account #

Trade References:
Name:     Contact:    Phone:
Fax:     Account #

Name:     Contact:    Phone:
Fax:     Account #

Name:     Contact:    Phone:
Fax:     Account #

For the purpose of establishing credit with Weld Direct Corporation, the answers given above are true and correct and I grant permission to consult the references listed and any other sources for the purpose of ascertaining credit information.

Name:     Title:     Date:

E-mail address:

Note: This form may be either completed on-line and submitted by clicking the button below or  printed  then faxed to us at (904) 387-5224.  If printed and faxed, please sign your name in addition to your providing your e-mail address.