Join an Industry Credit Exchange Group Company Information Company Name*DBA/Trade NameMember Number (Please enter 000 if none)*Is your company a member of any other Credit Association? (Yes/No) If yes, please note with which association)*Is your company a member of any other trade groups? If so, please list them and who facilitates them:*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website (https://www.XXXX.com)* Company's Fiscal Year End (MM/DD)* MM slash DD slash YYYY Federal Employment Id Number (FEIN Tax ID)*Federal Employment Id Number used to file US Taxes; if from another country, enter your company's government id number. Year Business Established*Legal Structure*CorporationS CorpProprietorshipPartnershipLLCOwnership Type*Publically TradedPrivately HeldAnnual Sales Revenue*Under $5 Million$5 Million - $15 Million$15 Million - $25 Million$50 Million - $100 MillionOver $100 MillionCompany A/R System*SAPOracleEclipseMAS90PeachtreePeopleSoftCforiaQuickbooksGetPaidSungardWorkflow AREpicorSpruceware.netCreditPointeHigh RadiusDynavisticsTermSyncForsevaCMSBilltrustCustomOther:Number of Customer Accounts*Sales Region*New England AreaNortheastern USNationallyInternationallyImporter/Exporter of Goods & ServicesImporterExporterImporter & ExporterNot ApplicableType of Business*ManufacturerWholesalerDistributorService ProviderRetailerFinancial ServicesOtherSIC Code/NAICS Industry Classification Code (if unknown, please enter 0000)*Is your company in one of the following industry segments?NoEastern US Petroleum DealersWholesale Plywood & LumberElectrical Wholesaler/DistributorPlease list the business types/industries/channels you sell to/service:Is your company a wholesale distributor who sells products either through their own terminal facilities or on a throughput basis, at host terminals.* Yes No Does your company's rack sales exceed 4 million barrels annually in the New England, New York, New Jersey, Atlantic coast and/or the Midwest areas.* Yes No Is your company part of a buying group or cooperative consisting of members who are owners or controllers of retail lumber or retail building material entities.* Yes No Does your company operate a retail lumber entity?* Yes No Does your company have a record of judgments, liens, attachments and/or bankruptcy filings within the past 5-years?* Yes No Is your company engaged in the manufacturing of electrical related materials?* Yes No Products & Services Sold*Please provide 10 customers (Names, City, State):*The information supplied in this company profile will be used to assess a company’s suitability to participate in a BCI industry credit exchange group. Please list your top 5 competitors:*The information supplied in this company profile will be used to assess a company’s suitability to participate in a BCI industry credit exchange group. Does your company submit A/R electronically to any credit bureaus or reporting agencies?*YesNoIs your company affiliated with, owned or operated by a debt collection business or commercial credit reporting agency?*YesNoFinancial Officer/Controller Name**Financial Officer/Controller Email* AP Contact Name:**AP Contact Telephone:*AP Contact Email:* How did you learn about BCI?* Website Online Search Current customer referral Check services your company is interested in:* Select All Commercial/International Credit Reports Consumer Credit Reports Credit Reference Checking and/or Application Processing Services Industry Trade Exchange Credit Group Special Interest Groups Commercial Collections/Recovery Services Credit Education & Professional Certification Programs Employment Services Credit Policy Consultancy Terms and Conditions Upon receipt, your application will be reviewed. Applications accepted will be processed and an invoice will be sent to you. Once payment is received in full, your access to BCI/NACM-New England Inc. services will be activated. I understand that company fees for products and services are due upon invoice. Annual service fees for membership and groups are set at the prevailing rates, are subject to change and continue from year-to-year unless notice of cancellation in writing is given at least 30 days in advance of annual renewal date and that my company is responsible for such charges. I understand that there are no refunds, including fees for unused services. Any amount past due is subject to a monthly 1.5% finance charge. The applicant hereby agrees to pay interest or late charges on all unpaid invoices for products and services from the date due until all sums are paid in full, at the lesser of one and one half percent (1-1/2%) per month, compounded monthly, or at the highest contract rate allowed by law. All costs of collections, before and after judgment, including but not limited to court costs, interest and reasonable attorney fees. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age: because all or part of the applicant’s income devices from any public assistance program: or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission. The applicant certifies that the statements contained in the application are accurate, that he/she will abide by the BCI/NACM-New England Inc. bylaws and regulations, and that he/she has the authority to execute this agreement on behalf of the applicant company.I agree to the Terms & Conditions* Yes No Signature / Title*Professional Designation:Years in Credit Profession:*# of Credit & Collections Staff:*Email* Telephone Number*Date* MM slash DD slash YYYY CaptchaNumberNumberNumberNumber