Credit Application – Jack Rich Lubricants

Main Office:

Jack Rich Lubricants, Inc.

617 Altamont Blvd.
Frackville, PA 17931

570-622-3000

Warehouse:

230 Jackson St.
Port Carbon, PA 17965

Jack Rich Lubricants Keep You Moving

Office Hours:

Monday – Friday: 8:00 am – 4:00 pm
Saturday & Sunday: Closed

Sales Tax Exemption Form (PDF)

* Please Complete The Credit Application Form Below
Completion and submission of the information is not an acceptance of extending credit nor binding on Jack Rich to provide credit. A Jack Rich representative will contact you with respect to your application.
Contact Jack Rich Lubricants with questions.

Commercial Credit Application

Company Name(Required)

President(Required)

Delivery Address(Required)

Street Address Address Line 2 City State ZIP Code

Same as Delivery Address

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Business Phone(Required)

Business Fax

Email Address For Accounts Payable(Required)

Business Website

Business Federal ID (EIN)(Required)

Business County

How Long In Business (in years)(Required)

Please enter a number from 0 to 100.

Have you ever dealt with our company before?(Required)

What is your anticipated Monthly Volume with our company (in dollars)?(Required)

Bankruptcy(Required)

Has any company officer or has the company ever filed for bankruptcy?

Yes

No

Financial Information

Primary Bank(Required)

Account No(Required)

Bank Phone(Required)

Bank Fax(Required)

Bank Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vendor References

Vendor Reference #1(Required)

Business Name

Address

Phone

Fax

Account Number

Vendor Reference #2(Required)

Business Name

Address

Phone

Fax

Account Number

Vendor Reference #3(Required)

Business Name

Address

Phone

Fax

Account Number

Payment can be made by credit card, however, there will be a 2% processing fee assed.

Finance charges are accrued on accounts not paid within terms of account. The finance charge is computed by a periodic rate of 1 1/2% per month (18% per year) on unpaid balance. Any and all collection agency fees, court costs, attorney and miscellaneous fees will be claimed should your account be placed for collection for any reason.

Your Name(Required)

First Last

Title(Required)

Email(Required)

Enter Email Confirm Email

Phone(Required)

Signature(Required)

eNewsletter, Promos & Notifications

Yes - Sign Me Up!

Email

This field is for validation purposes and should be left unchanged.