Brita Safety

Purchase Order Account Application

NOTE: If you already have an account with us, please login at the login page.

Company Details

* Required information

Company Name:
Street Address:	*
City:	*
Post Code:	*
Country:	*
Telephone Number:	*
Fax Number:
Credit Amount Requested : $	*
Length of time in business:	*
Company Type:	*
Number of employees:	*

Credit References: Give complete Name, Address, Phone Number, and Fax Number

Reference 1:	*	Address:	*
City:	*	State:	*
Phone:	*	Fax:	*

Reference 2:	*	Address:	*
City:	*	State:	*
Phone:	*	Fax:	*

Reference 3:	*	Address:	*
City:	*	State:	*
Phone:	*	Fax:	*

Accounts Payable Contact:

Gender:	Male Female *
First Name:	*
Last Name:	*
E-Mail Address:	*
Telephone Number:	*

Options

Newsletter:

CATEGORY_POACCOUNT_PASSWORD

Password:	*
Password Confirmation:	*

TERMS: NET 30

A FINANCE CHARGE of 2% per month (APR 24%) will be added to all outstanding amounts after 30 days from date of invoice.

If this account is refereed to a third party collection agency all associated collection cost will be paid by you, the customer.

Authorization is granted to make credit inquires with the references listed above. BY CLICKING THE SUBMIT BUTTON BELOW I HAVE READ THE ABOVE AND AGREE TO COMPLY WITH THE TERMS OF PAYMENT AND OTHER STATED CONDITIONS.