Payment Terms Application Form

Net 30 payment terms are offered to approved, established companies and government agencies

Please fill in this form with complete information, attach your purchase order, sign it and submit.

Applications will be reviewed by American Conex Management within three business days

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American Conex Order #

Begins with 300XXXXX

Company or Agency Name *

Company or Agency Website / URL *

Example: https://yourwebsite.com

Number Of Years in Business

• 0 - 1 Year
• 1 - 2 Years
• 2 - 5 Years
• 5+ Years

Main Company or Agency Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Shipping Container(s) Delivery Address (if different to Company/Agency Address)

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Accounts Payable Contact Person *

First

Last

Accounts Payable Contact Phone *

Accounts Payable Contact Email *

Purchase Order File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

A signed purchase order issued by your company/agency must be submitted with all credit applications. Payee is: American Conex LLC, 4615 NW 53rd Ave Suite B, Gainesville, FL, 32653, USA You can upload it now, or email it later to sales@americanconex.com

Name of person making this application *

First

Last

Your Email Address *

Your Phone Number *

Today's Date *

Agree to the terms and conditions *

• I hereby certify that I am authorized to sign this purchase order application on behalf of the company or agency listed on this form. I further certify that I have read, understood and agree to the purchase order terms and conditions listed here

Submit