Customer Application Form

Please fill out the form below to apply for credit terms with Alliance Chemical.

📋 Required Information

Business Details: Legal company name, Tax EIN (XX-XXXXXXX format), industry, incorporation details

Contact Information: Business emails only (no personal Gmail/Yahoo accounts)

Business Description: Describe your business and chemical needs

Addresses: Complete billing and shipping addresses with proper City, State ZIP format

References: Trade references optional but recommended

Credit Amount: Between $1,000 - $1,000,000 initial request

⚠️ Note: Test data (companies with "test", "demo", "example" in the name) will be automatically rejected. Please provide real business information for credit evaluation.

Forms & Documents

Credit Application

Download and complete the PDF version

Download PDF

IRS Form W-9

Tax form for business transactions

Download W-9

Note: Complete and email forms to sales@alliancechemical.com if you prefer not to use the online form.

Address Information

Billing Address

Street Address *

City *

State *

ZIP Code *

Shipping Address

Street Address *

City *

State *

ZIP Code *

Credit Terms & Financial Information

Requested Credit Amount ($) *

Tax Exempt Status *

YesNo

Does your company use a payment portal? *

YesNo

Primary Buyer Email *

Accounts Payable Email *

Invoice Email Address

Bank & Trade References

How would you like to provide references?

Upload Reference DocumentsEnter Details Manually

Bank Reference (Required)

Trade References (optional)

Trade Reference #1

Trade Reference #2

Trade Reference #3

Terms and Conditions

I agree to the Terms and Conditions and acknowledge that I have read and understood the credit application requirements. I certify that all information provided is accurate and complete. *