Purchasing Account Application Company InformationLegal Company Name*DBA NamePrimary ContactEmail* Phone*Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Shipping Address the same as Billing?* Yes No Shipping not Require (Pick-up at Stoll) Choose your desired default shipping option. Shipping location can be modified if desired when placing each order.Shipping Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Shipping Location Type* Residential Commercial Do you have a loading dock or forklift to receive pallet shipments at this location?* Yes No If you do not have a loading dock or forklift, a Liftgate will be required for freight shipments to your location.Stoll Product LinesWhat products/services are you interested in?* Glass Metal Fabrication Services CommunicationAccounts Payable ContactAccounts Payable Email* Order Confirmation Email #1* Order Confirmation Email #2 Order Confirmation Email #3 Payment TermsChoose your preferred payment terms* Auto Pay Before Process 30 Day Terms Please contact our Accounting Department to place a credit card on file or discuss payment options for Auto Pay Before ProcessNet 30 Terms are subject to credit approval, and any additional conditions outlined below.Terms & Conditions PAY BEFORE PROCESS TERMS: Pay Before Process Terms require that payment be made in full before production begins. Please contact our Accounting Department to place a Credit Card on file, or to discuss additional payment options. PRODUCTION CHANGES: Products enter a production queue within 2 days of orders being placed. Changing or canceling an order after production has started may incur additional fees. CHECK POLICY: If you choose to pay by check and your check is dishonored, you agree to pay a service fee of $35, or any higher amount allowed by law, and we may electronically debit or draft your account for this fee. Also, if your check is returned for insufficient or collected funds, your check will be electronically re-presented for payment. Stoll Industries reserves the right to reduce credit limits and/or eliminate credit terms for any account presenting a bad check. DUN & BRADSTEET DISCLOSURE: In an effort to assist you in building a strong company profile, Stoll reserves the right to report all account activity to Dun & Bradstreet. This is a powerful tool your company has access to at any time. It is a service Stoll offers to assist you in monitoring your company’s payment history and credit worthiness. I certify that the information provided on this form is true, current, and complete. I have read and agree to the Terms & Conditions, and I hereby authorize Stoll Industries to charge the card information on file for any orders placed.Terms & Conditions NET 30 TERMS: Net 30 Terms require that payment be made in full within 30 days from date of Invoice. Date of Invoice will be the same day that your product is marked as shipped. Net 30 Terms are subject to credit approval. Stoll Industries reserves the right to decline any request for payment terms, or to revoke these terms at any time. OVERDUE ACCOUNTS: Stoll Industries will automatically hold shipment of all product once an account goes into overdue status. Items placed on hold for an extended period of time may be subject to storage fees. In order to receive your shipments in a timely manner and avoid any fees, please keep your account current. PRODUCTION CHANGES: Products enter a production queue within 2 days of orders being placed. Changing or canceling an order after production has started may incur additional fees. CHECK POLICY: If you choose to pay by check and your check is dishonored, you agree to pay a service fee of $35, or any higher amount allowed by law, and we may electronically debit or draft your account for this fee. Also, if your check is returned for insufficient or collected funds, your check will be electronically re-presented for payment. Stoll Industries reserves the right to reduce credit limits and/or eliminate credit terms for any account presenting a bad check. DUN & BRADSTEET DISCLOSURE: In an effort to assist you in building a strong company profile, Stoll reserves the right to report all account activity to Dun & Bradstreet. This is a powerful tool your company has access to at any time. It is a service Stoll offers to assist you in monitoring your company’s payment history and credit worthiness. I certify that the information provided on this form is true, current, and complete. I have read and agree to the Terms & Conditions, and I hereby authorize Stoll Industries to request and receive Credit and Bank information for the purpose of securing an open line of credit with their company.Signature First Last