Customer/Credit App

Clean Coast Technologies Inc.

1041 Thomas Ave Pasadena, Texas 77506

Office: 713-378-0000 Fax: 713-378-0404
Email: info@cleancoasttech.com

ACCOUNT APPLICATION

* Required Fields

Name  
Legal Name of Business
 
DBA (if different)  
Street Address  
City
State Zip
 
Ship to Address  
Billing Address  
Telephone
Fax
 
Fedral Id #
Tax Exempt #
 
TYPE OF BUSINESS *:  
 
Purchasing Contact
Phone
 
Accounts Payable Contact
Phone
 
TERMS REQUESTED:  
 
 
BANK REFERENCE:   
Name  
Address  
City
State Zip
 
Phone
Fax Bank Officer
 
TRADE REFERENCES:  
Name
  Name
 
Address
  Address
 
City
  City
 
State,Zip
  State,Zip
 
Phone Number
  Phone Number
 
Fax Number
  Fax Number
 
Company Name
  Company Name
 
E-mail
  E-mail
 
     
Name
  Name
 
Address
  Address
 
City
  City
 
State,Zip
  State,Zip
 
Phone Number
  Phone Number
 
Fax Number
  Fax Number
 
Company Name
  Company Name
 
E-mail
  E-mail
 
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