World Headquarters

29830 Beck Road

Customer Profile Form Wixom, MI 48393
Phone: 248-624-5555
Fax: 248-926-4338

Please complete ALL fields. Please Return to nlbcreditapps@nlbusa.com

COMPANY DETAILS
Company Name: Date Business Commenced:

Phone/Fax Number:  Sole Proprietorship Federal Id Number:

 Partnership
E-mail Address: Est. Monthly Limit:
 Corporation

Registered Company  Other

Address, State, Zip Code
Years in Business:

Describe Principle
Business Activity
INVOICING DETAILS
AP Contact Name and
Invoicing Address:
Phone Number:
 USPS
(If Different than Above) Invoicing Mailing Preference:
 E-mail
PURCHASING DETAILS
Purchasing Contact: Authorized Purchasers:

 Yes If yes, please attach tax

Phone Number: Tax Exempt:  No exempt certificate.

 Partial Shipment
Prepaid Freight Number: Shipment Preferences:
 Complete Only
BANK REFERENCE DETAILS
Bank Name: Account Number:

Contact Name: Contact Email:

Phone Number:

TRADE REFERENCE DETAILS

Company Name: Company Name:

Phone Number: Phone Number:

Contact Name: Contact Name:

SIGNATURE: _____________________________________________ DATE: ______________________________

The above company (Applicant) hereby applies to NLB Corp. for an open credit account for goods, services, and / or rentals under the terms and conditions set forth in this Application. The
Applicant authorizes NLB Corp. to investigate the Applicant’s credit history and that of the principals. Applicant agrees to pay for all purchases made under any Account established by this
application. The Company’s payment terms are Net 30 days from the date of invoice unless otherwise agreed to. Items past due will incur a monthly service charge of 1.5% interest (18%
APR) Applicant and the NLB Corp. agree that all transactions, between them shall be deemed to have been made in the State of Michigan and shall be governed by the laws of the State of
Michigan. Any legal action related to any transactions can be filed in any court in the State of Michigan. The undersigned states that he/she is duly authorized to apply for credit with NLB
Corp. on behalf of the Applicant; that the information set forth herein is correct to the best of his/her knowledge, and that he/she has read the foregoing terms and conditions, and agrees
to such terms on behalf of the Applicant.

FOR NLB CORP. USE ONLY

Salesman: Industry Type:
Comments: