Commercial Application | Coosa Valley Electric

Name of Business(Required)

Name of Principal Contact(Required)

First Last

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Shipping Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Tax Number(Required)

Type of Establishment(Required)

How long have you been in business?(Required)

Persons authorized to sign purchase orders(Required)

1st Credit Reference Name(Required)

First Last

1st Credit Reference Address(Required)

Street Address Address Line 2 City State ZIP Code

1st Credit Reference Phone(Required)

2nd Credit Reference Name(Required)

First Last

2nd Credit Reference Address(Required)

Street Address Address Line 2 City State ZIP Code

2nd Credit Reference Phone(Required)

3rd Credit Reference Name(Required)

First Last

3rd Credit Reference Address

Street Address Address Line 2 City State ZIP Code

3rd Credit Reference Phone(Required)

Bank Reference(Required)

Bank Account Number(Required)

Member Electronic Signature (Full Name)(Required)

Commercial Propane