NEW ACCOUNT APPLICATION        Complete Form Online & Email back to Sender.  Or Print, Complete, & Fax back to: 269‐273‐3244 Company Name  Phone  Fax 

        Company Billing Address  City  State  Zip 

           Company Shipping Address  City  State  Zip 

           Purchasing Contact 1  Phone  Phone Ext.  Fax  Email 

              Purchasing Contact 2  Phone   Phone Ext.  Fax  Email 

              Accounts Payable Contact 1  Phone   Phone Ext.  Fax  Email 

              Accounts Payable Contact 2  Phone   Phone Ext.  Fax  Email 

              

Type of Business    ○    Retailer     ○    Manufacturer     ○    Re‐Distribu on     ○    Other: Tax ID#, or EIN Current W‐9 must accompany this application 

 Tax Exempt# (if Applicable)  MUST include copy of Exempt Certificate 

DUNS# 

        Business Category 

  ○    Sole Proprietor    ○  Partnership     ○   LLC     ○   Corpora on  State of Incorporation: 

  ○  Government      ○  Other: 

Preferred Payment Method:   ○    Credit Card   (we accept all major) 

  ○  PayPal     ○  Company Purchase Order/Check  (only with approved accounts) 

   ○   Wire Transfer    ○  Other: 

TRADE REFERENCES—Please supply a minimum of 3 references.  Send a separate sheet if necessary. 

A Veteran Owned Small Business

Phone: 1.800.870.6189 Fax: 1.269.273.3244 Web Store: www.SafetyGlassesUSA.com

1501 KDF Drive Three Rivers, MI 49093 A Certified HUBZone

Reference 1 

Company Name Phone Fax

      Company Address City State Zip            Account# Account Contact Contact Phone Contact Email            Company Name Phone Fax       Company Address City State Zip            Account# Account Contact Contact Phone Contact Email            Company Name  Phone Fax       Company Address City State Zip            Account# Account Contact Contact Phone Contact Email            

Reference 2 

Reference 3 

Page 1 of 2 

“We Have Your Protection In Sight”

As an authorized agent of ______________________________________  I am reques ng to open a credit account with Safety Glasses USA, Inc. and authorize its agents to conduct a credit inquiry based on the informa on provided, including business and trade references, and any Financial Ins tu on informa on provided on this and any addi onal related pages.  I cer fy by my signa‐ture, that all informa on provided is true and that I am authorized to sign on behalf of my company.   

Signed:   ______________________________________Title: _____________________Date: _____________  Printed Name: _________________________________Title: _____________________Date: _____________ 

APPROVED DENIED DATE

CUST. # ORDER #

TERMS  AND CONDITIONS Ini al each line a er you have read and agree 

Payment is due within 30 days of ship date shown on invoice.  

It is your company’s responsibility to submit any vendor informa on to Safety Glasses USA, Inc. that is required for your Accounts Payable Department prior to, or upon placement of, your first  order.  Failure to do so will not be the responsibility of Safety Glasses USA, Inc., and will not be used as a means to delay payment.  

If payment is not made within 30 days, your account will be assessed a 2% Finance Charge every 30‐day billing cycle un l payment is made in full on the invoice.  Once assessed, Any Finance Charges or late fees may not be removed.  No par al payments on an order will be accepted.  A er 90 days of non‐payment, your account will be suspended and all future orders held for shipment.  The account will then be turned over to our Collec ons Department. 

 

All packaging errors, order errors, or product defects must be brought to the a en on of Safety Glasses USA, Inc. immediately upon receipt.  Any war‐ranty issues may be brought to the a en on of Safety Glasses USA, Inc. whereupon you may be re‐directed to the manufacturer. 

 

All Purchase Orders must be e‐mailed, mailed, called in, or faxed to us.  A confirma on will be sent back to you with an Order Number.  Open invoice (or Net 30) orders can not be placed on the internet at this  me.      

Any Net 30 or Invoiced order under $50.00 will be subject to a $10.00 minimum order surcharge.  To avoid this surcharge, you may increase your order total, or pay by credit card.   However, once the order is shipped and/or invoiced the surcharge cannot be removed. 

 

Failure to comply with the terms of this agreement may result in loss of special pricing or discounts for exis ng orders both shipped and unshipped, which are unpaid, as well as future orders.  Safety Glasses USA, Inc. reserves the right to suspend or revoke credit account privileges at any  me.  Credit Card informa on may be required for accounts that become delinquent. 

Thank You. We look forward to establishing a long and mutually rewarding business relationship with your company.

Checklist of Required Items to be submitted with this Application for Account Consideration: Sent Your Company’s W-9 to SGUSA Received SGUSA’s W-9 for your Accounts Payable Dept. Sent Your Company’s Tax Exempt Certificate if applicable.

SGUSA W-9 SENT APPLICATION SENT DATE

FOR OFFICE USE ONLY

Page 2 of 2 

Bank Name  Branch Phone Fax       Branch Address City State Zip            Account# Account Contact Contact Phone Contact Email            

Bank

 Referen

ce 

BANK REFERENCE 

Amount of Credit your company is reques ng per month or 30‐day cycle:  

NEW ACCOUNT APPLICATION   ‐cont’d 

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