Vertra Customer Setup Application

VERTRA – CUSTOMER SETUP FORM AND CREDIT APPLICATION

Step 1 of 7

14%

Business Information
Applicant Legal Business Name*
Applicant DBA (If Applicable)
Federal Tax ID/Registration #*
DUNS # (If Applicable)
Entity Type*
Mth/Yr Business Opened*
State of Incorporation*
Sales Rep Name*
Upload Resale Certificate (PDF)

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Contact Information
Billing Contact Name*
Billing Contact Phone*
Billing Contact Email*
- Buyer Same as Billing Contact
Buyer Contact Name*
Buyer Contact Phone*
Buyer Contact Email*
Billing Address Line 1*
Billing Address Line 2
City*
State*
Zip Code*
Country*
- Shipping Address Same as Billing Address
Shipping Address Line 1*
Shipping Address Line 2
City*
State*
Zip Code*
Country*

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Shipping and Terms
Shipping Terms*
If Collect, Carrier Collect #
Preferred Shipping Method*
Routing or Other Method
Payment Terms*
Applicant Sells Via Ecommerce?*
- Yes
- No
Does Applicant have an account with Wells Fargo Factor?*
- Yes
- No
If yes, Applicant Wells Fargo Factor Acct #
Credit Line Amount Requested (USD)*

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Owners/Officers
Name*
Title*
Phone*
Email*
Name
Title
Phone
Email
Name
Title
Phone
Email

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Bank Reference
Bank Name*
Bank Contact Name*
Bank Contact Phone*
Bank Contact Email*
Bank Address Line 1*
Bank Address Line 2
City*
State*
Zip Code*
Country*

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Trade References
Trade Reference 1 Business Name*
Trade Reference 1 Contact Name*
Trade Reference 1 Contact Phone*
Trade Reference 1 Email*
Trade Reference 1 Address Line 1*
Trade Reference 1 Address Line 2
City*
State*
Zip Code*
Country*
Trade Reference 2 Business Name*
Trade Reference 2 Contact Name*
Trade Reference 2 Contact Phone*
Trade Reference 2 Email*
Trade Reference 2 Address Line 1*
Trade Reference 2 Address Line 2
City*
State*
Zip Code*
Country*

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ENI-JR286, Inc., is factored by Wells Fargo Capital Services, Inc. (WF), - 100 Park Ave, 3rd Floor, New York, NY 10017, Fax#: 212.703.3597 or 212.703.3590 - who services our customer credit requirements. In order for WF to start the process of extending credit to your company, the information requested above is required. WF reserves the right to ask for additional information. All information requested will be used for your benefit and to help make a sound credit decision of your company. Please complete the information above and return it promptly to our sales representative. Our acceptance of the credit application does not constitute the opening of an account. This application is subject to credit and sales approval. All information provided in this application and any additional information provided is true and complete. Upon accepting this application and establishment of a customer account number, I confirm the acceptance of ENI-JR286’s terms and conditions. I understand that these terms and conditions are in effect for any and all orders placed.
Legal Representative Signature
Full Name*
Title*
Date*
Confirmation*
- Yes, I Confirm
By checking this box, I confirm that all information provided in this application and any additional information provided is true and complete. Upon accepting this application and establishment of a customer account number, I confirm the acceptance of ENI-JR286’s terms and conditions. I understand that these terms and conditions are in effect for any and all orders placed.
Signature*

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VERTRA – CUSTOMER SETUP FORM AND CREDIT APPLICATION

Step 1 of 7

Business Information

Contact Information

Shipping and Terms

Owners/Officers

Bank Reference

Trade References

Legal Representative Signature