Regal Components, Inc. - Credit Application

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We gladly accept:

Now In: Credit Application

You will have the added payment option of Purchase Order when placing your orders online or by phone/fax.

You may be eligible for discounted pricing based on certain qualifying criteria.

Please fill out and submit our online application form below, or, if you would prefer, print and mail/fax the

Please enter your company and contact information below.

*Company Name:
Business Entity:	Corporation Partnership Sole Proprietorship Other
No. of Employees:
*Federal Tax ID or SSN:
Business Type:	Molder Mold Maker Other
*Principal Name:
*Title:
Purchasing Contact:
Title:

Please enter your billing information below.

*Address:
*City:
*State/Province:
Zip:
*Country:
*Phone:
Email:
Fax:

Please enter your shipping information below. (Same as Billing)

*Address:
*City:
*State/Province:
Zip:
*Country:
*Phone:
Email:
Fax:

Please enter your bank information below.

*Bank Name:
*Bank Address:
*Bank City:
*Bank State:
Bank Zip:
*Bank Country:
*Account Number:
Loan Officer:

Please enter your trade references below.

*Company Name:
Account Number:
*Address:
*City:
*State/Province:
Zip:
*Country:
Phone:
Email:
Fax:

*Company Name:
Account Number:
*Address:
*City:
*State/Province:
Zip:
*Country:
Phone:
Email:
Fax:

*Company Name:
Account Number:
*Address:
*City:
*State/Province:
Zip:
*Country:
Phone:
Email:
Fax: