Customer Application Company Name* DUNS #* Billing Contact* Title Email Address for Invoicing* Email Address for Invoice Inquiries* Phone*Billing Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you exempt from sales tax?* Yes No Please provide your tax exemption form*Accepted file types: doc, docx, pdf, txt, Max. file size: 100 MB.Type of Entity* Corporation Proprietorship Partnership Other If other, indicate hereIf you are a proprietorship or partnership please give the name, address, and telephone number of the owner(s)Owner 1* Title 1* Owner 2* Title 2* BANK REFERENCESBank References (Name / City / State) Bank Reference Name 1* Bank Reference Email 1* Bank Reference Phone 1*Bank Reference Account # 1*Bank Reference Name 2* Bank Reference Email 2* Bank Reference Phone 2*Bank Reference Account # 2*TRADE REFERENCES (Name / City / State) (Minimum of 3)Trade Reference Name 1* Trade Reference Email 1* Trade Reference Phone 1*Trade Reference Name 2* Trade Reference Email 2* Trade Reference Phone 2*The undersigned, being duly authorized, hereby states that the information provided in this credit application is true and correct. Further, (Company Name) agrees to pay all invoices according to the terms listed in the Merryweather (company name) Foam Standard Terms and Conditions form. Any exceptions must be pre-approved in writing. We authorize our bank and suppliers to furnish Merryweather Foam with information needed to complete this credit evaluationCompany Name* Name* First Last Title Signature*Date* MM slash DD slash YYYY