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Net 30 Terms

Credit Application

Complete the form below to apply for 30-day payment terms. Fields marked * are required.

01Business information

Legal company name *DBA (if any) Business type (Corp, LLC, etc.) Federal Tax ID / EIN Years in business Phone *

Business address *

02Contacts

Primary contact *Title Email *Accounts payable contact Accounts payable email Requested credit limit ($)

03Bank & trade references

Bank name Bank contact / phone

Trade references (company, contact, phone — up to 3)

04Agreement

I certify the information is accurate, authorize Uni-Chem Solutions to verify references, and agree that invoices are due within 30 days of the invoice date.Authorized signer (full name) *