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Credit Application and Sales / Use Tax Verification
APPLICANT'S NAME AND ADDRESS:
 LEGAL NAME OF COMPANY
  TRADE STYLE
  FAX NUMBER
CONTACT NAME
 Email
 STREET ADDRESS
  CITY, STATE
  ZIP CODE
 ADDRESS FOR INVOICES
  CITY/STATE
  ZIP CODE
 TELEPHONE NUMBER
  TYPE OF BUSINESS: I.E., CORP.,
SUB. "S" CORP., PARTNERSHIP, ETC.
 NATURE OF BUSINESS
  STATE OF INCORPORATION/
REGISTRATION





















APPLICANT'S TRADE REFERENCES:
 SUPPLIER: NAME,
ADDRESS, CITY, STATE and
ZIP CODE

  CREDIT MANAGER
 ACCOUNT
NUMBER
  TELEPHONE NUMBER
 SUPPLIER: NAME,
ADDRESS, CITY, STATE and
ZIP CODE

  CREDIT MANAGER
 ACCOUNT
NUMBER
  TELEPHONE NUMBER
 SUPPLIER: NAME,
ADDRESS, CITY, STATE
and ZIP CODE

  CREDIT MANAGER
 ACCOUNT
NUMBER
  TELEPHONE NUMBER
Bank Reference:
BANK
   ACCOUNT NUMBER
   BANK OFFICER
  ADDRESS

   CITY / STATE

  ZIP

PHONE NUMBER
 NAME AND POSITION
 SIGNATURE ( For printing and faxing / mailing )
Please fax signed, completed applications to: 847-701-0381.

 DATE









SALES / USE TAX VERIFICATION:
Purchaser:
The undersigned certifies that all the information listed below is correct:
Type of activity:   Please be specific.
 Manufacturer  
 Wholesaler  
 Retailer  
 Contractor  
 Other (specify)  
 Purchaser intends to buy chemicals from Shamrock Chicago Corp. in the regular course of its business.
Any of such property purchased from Shamrock Chicago will be:
Resold as tangible personal property in the same form as received.
Used as an ingredient or integral part of an end product for sale by manufacturing, processing, etc.
Other (specify)
 Sales and/or use tax on all tangible property purchases are to be handled as follows:
All purchases are Taxable.
Some purchases are taxable, others are exempt.
THE PURCHASE ORDERS WILL CLEARLY INDICATE CORRECT TAX STATUS.
Blanket exemption for resale.
Blanket exemption for other statutory reason (specify).
Purchaser assumes all liability for payment of the tax if the property purchased is used
or consumed in such a manner as to render the sale of said property subject to tax. Should
the State refuse to honor this certification and assess sales or use tax against Shamrock
Chicago, the undersigned will reimburse Shamrock Chicago Corp. the amount of such
tax, penalties and interest.


















State:

Registration Number:

Purchasers:
  By
Title
 SIGNATURE ( For printing and mailing )

DATE
Place any comments or questions here: