Legal Company Name (required)

Select Floworks Business Unit (required)
---Sunbelt Supply - USASunbelt Supply - CanadaSunbelt Supply - ShanghaiNational Valve - USATriple S - USAOEC - USAGenesis - USA

Please select business type (required)
---Sole ProprietorshipPartnershipCorporationNon Profit OrgJoint VentureLLC

FloWorks Salesperson Name (required)

DBA

Street Address (required)

City (required)

State/Province (required)

Zip (required)

Mailing Address

Streeet Address (required)

City (required)

State/Province (required)

Zip (required)

Country (required)
---AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

Main Phone # (required)

Main Fax #

Email Address (required)

Are you sales tax exempt (required)
---YesNo

Contact Information

A/P Contact (required)

A/P Phone # (required)

A/P Email (required)

A/P Fax #

Business Start Date

Dun & Bradstreet #

Fed. Tax ID No.# (required)

Credit Line Requested

Method of Payment (required)
Please Attach any pre-printed documents below. Send wire payment information to remittance@floworkspvf.com.
---ACHCheckWired

Company Website

Name of Business Owner(s)/Officer(s):

Type of Business (required)
---ManufacturerDistributorBrokerFabricatorEPCOther

Bank References

Attach all the pre-printed references below.

Bank Name

Bank Contact Name

Bank Address

Bank Phone #

Bank Account Number

Bank Fax #

Bank Email Address

Trade References (3 references required)

Attach all the pre-printed references below.

Trade Reference 1

Name

Contact Name

Street Address

City

State/Province

Zip/Postal Code

Main Number

Fax Number

Email Address

Trade Reference 2

Name

Contact Name

Street Address

City

State/Province

Zip/Postal Code

Main Number

Fax Number

Email Address

Trade Reference 3

Name

Contact Name

Street Address

City

State/Province

Zip/Postal Code

Main Number

Fax Number

Email Address

We hereby represent that we are authorized to submit this application on behalf of the Buyer named herein, for the purpose of obtaining credit, and that the information (including any requested financial statements) provided to Floworks International LLC and/or its subsidiaries and affiliates (collectively, “Seller”) is warranted to be true, accurate and complete. We hereby authorize Seller to request credit reports from credit bureaus (including consumer reporting agencies) regarding Buyer’s respective commercial credit and to otherwise investigate their respective creditworthiness before extending credit now or at any time in the future. We further represent that the Buyer has the financial ability, solvency, and capability to pay for all invoices within the agreed upon terms. Unless otherwise agreed in writing, Buyer agrees to Seller’s payment terms of net 30 days from invoice, payable in U.S. dollars. Buyer agrees that all Terms and Conditions of Sale, attached below, may be amended from time to time, and shall apply to all sales and extensions of credit made to Buyer by Seller. All information obtained is kept confidential by Seller.

I acknowledge the statement above

Terms & Conditions of Sale

Do you accept these terms? (required)
---YesNo

Print your Name (required)

Today's date (required)

Attachments

For all questions or concerns, please contact CreditTeam@floworkspvf.com.