Send a Message
Instructions: If your business would like to sign up for our payroll deduction package, please fill out the following form, and push the "Submit Form" button at the end of the page. A representative will be in touch with you within 1 business day about your application and to help you set up the rest of your account.

Required items indicated with *.
GENERAL INFORMATION  
  Business Name:*
  Business Phone:*
  EMail Address:*
  DBA (Doing Business As):
  Fax:
  Tax ID:*
  Street:*
  City:*
  State:*
  Zip:*
  Accounts Payable Contact:
  Requested Line of Credit:*
  Year Established:*
  Form of Business:*
  Owner's Name:*
  Social Security # of Owner:*
     
BANK REFERENCE  
  Name of Bank:*
  Account #:*
  Street:*
  City:*
  State:*
  Zip:*
  Business Phone:*
  Fax:
     
SUPPLIER REFERENCES (these should be references that can be contacted to show your history of making payments)
  Name:*
  Account #:*
  Street:*
  City:*
  State:*
  Zip:*
  Business Phone:*
  Fax:
     
  Name:
  Account #:
  Street:
  City:
  State:
  Zip:
  Business Phone:
  Fax:
     
  Name:
  Account #:
  Street:
  City:
  State:
  Zip:
  Business Phone:
  Fax:
     
PAYABLE INFORMATION  
  Unit Manager:*
  Business Phone:*
  District Manager:*
  Business Phone:*
  District Office Address:*
  City:*
  State:*
  Zip:*
  (Non-Profit Accounts) Funding Agency:
  Agency Address:
  City:
  State:
  Zip:
  Agency Contact (Name, Title):
  Phone:
     
PURCHASING INFORMATION  
*Please note that initials will be used in place of signatures in the following two sections, and represent a legally binding agreement.
  Anyone placing orders on our behalf is deemed authorized (Initial here):*
  Are purchase orders required to charge your account?:
  Is special billing or vouchering required?:*
  If yes, please describe here and attach sample of required forms below:
     
TERMS & CONDITIONS  
I hereby represent that I am authorized to submit this application on behalf of the customer named above, and that the information provided is for the purpose of obtaining credit and is warranted to be true. I/we hereby authorize Uniform Warehouse/Professional Uniforms, Inc. to investigate the references listed pertaining to my/our credit and financial responsibility. I understand that this may include obtaining written documentation of my personal credit report. It is agreed and understood that all necessary collection, legal expenses and interest (at 1.5% per month), may be charged to debtor in the event of default or failure to pay for goods sold and delivered. I/we further represent that the customer applying for credit has the financial ability and willingness to pay all invoices in full within the established terms.
  Electronic Signature :* Typing your full name into this box constitutes your consent to a legally binding agreement.
  Title:*
  Date:*
  Attach Additional Files: