Customer Onboarding & Credit Application

Welcome to the Quala Family, we’re glad you’ve decided to partner with us as a customer!

Please fill out the secure webform below to complete a credit application to be reviewed by our financial team. You can also download a print copy of the form below and return the completed form to QHL-CreditAppRequest@quala.us.com

Any payments made with a credit card are subject to a 2% processing fee. If credit is granted, terms are net 30 unless otherwise documented.

Requested Monthly Credit Limit *

Existing Customer?

• Yes
• No

If yes, what is your customer number?

Quala/PSC Representative Name

What services do you require?

• Tank Wash
• Tank Maintenance
• Industrial Services (QIS)
• Rail & Specialty Cleaning (QRS)
• IBC

Company Information

Legal Business Name *

Date Business Opened

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Doing Business As

Address

Address Line 1

Address Line 2

City

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

Zip Code

Phone

Fax

Parent Company Address

Address Line 1

Address Line 2

City

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

Zip Code

Nature of Business

Type of Business

• Corporation
• Partnership
• Proprietorship
• LLC

Company Director/Officer/Principal Information

(1) Name of Company Principal/Owner Responsible for Business Transactions *

First

Last

Title *

Email *

Phone *

(2) Name of Company Principal/Owner Responsible for Business Transactions

First

Last

Title

Email

Phone

Financial Contact Information

(1) Primary Financial Contact *

First

Last

Title *

Phone *

Email *

(2) Accounts Payable Contact *

First

Last

Title *

Phone *

Email *

Trade References

(1) Company Name *

Phone *

Fax

Company Contact *

First

Last

Address *

Address Line 1

Address Line 2

City

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

Zip Code

Number of Years Doing Business *

Account No. *

Credit Limit *

Current Balance *

(2) Company Name

Phone

Fax

Company Contact

First

Last

Address

Address Line 1

Address Line 2

City

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

Zip Code

Number of Years Doing Business

Account No.

Credit Limit

Current Balance

Special Billing Instructions

Quala/PSC Facilities or Regions for Service *

Tax ID Number *

Are you Tax Exempt?

• Yes (if yes, please provide tax exempt certificate)
• No

Is a Purchase Order # Required

• Yes
• No

How is Your PO # Obtained? *

i.e. Driver, BOL, etc.

What is the format of your PO# (i.e XXX-XXXX or 5 digits beginning with a 7) *

Bill to Location

Location Name/Terminal Number *

Address *

Address Line 1

Address Line 2

City

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

Zip Code

Email for Invoice Delivery *

Bill to Contact *

First

Last

Title

Phone *

Email *

Accounts Payable Contact *

First

Last

Title

Phone *

Email *

Method of Payment

Method of Payment *

• Check
• ACH
• Credit Card* (Payments made with a credit card are subject to a 2% processing fee)

Signature Section

Company Name (Please Type) *

Authorized Signature *

Clear Signature

Date *

Signatory Name *

Title

Upload W9 & Other Supporting Materials

Click or drag files to this area to upload. You can upload up to 5 files.

Submit

Payment and Invoicing

Payment for all services rendered, are due as stated on the invoice. Any item disputed, must be done so in writing within 30 days from the invoice date. Failure to initiate a dispute within this timeframe will waive your right to dispute that invoice. A dispute on a particular invoice does not waive your right to withhold payment on non-disputed invoices. The customer agrees to pay all costs of collection or legal fees should such action be necessary due to non-payment.

Failure to pay invoices in a timely manner may result in your account being placed on Credit Hold. Credit Hold may happen as early as 15 days from the due date stated on the invoice date. If your account is placed on Credit Hold, all services will be suspended until your account is brought in good standing.

Should your account continue to remain past due, the account may be placed in default and be turned over to legal counsel for further actions. Default status may happen as early as 60 days from the invoice due date.

Tax Exemption Status

If your Company is exempt from state Sales Tax, it is your responsibility to provide a valid exemption certificate at the time of this application or at such time when you become eligible for exemption. Upon receipt of a valid certificate, we will perform the necessary tasks to establish tax exemption to the account. All taxes invoiced prior to receipt of a valid exemption certificate must be paid in full.

Finance Charges and Non-Sufficient Funds (NSF)

We reserve the right to assess finance charges of 1% per month (12% per annum) on all invoices that are past due. Customers with past due amounts will receive a finance charge invoice each month. Finance charges will be assessed as of the end of the month and reduced by any amounts in dispute and any payments received by month-end but not posted. Customer agrees to pay $50 for each check issued, which is returned unpaid or marked NSF.

In signing this Application, customer agrees to all of the above and hereby grants permission for credit information to be verified by company(s) and financial institution(s) that the Customer has specified on this document and others that become evident during the credit review process. If the applicant is not a corporation, we are authorized to obtain credit reports on the proprietors, partners, or principals. The undersigned also understands that we will retain this application, whether it is approved or not, and that we will consider this application as a continuing statement of the undersigned’s financial position and situation until notified otherwise.

Faxed documents will be deemed as original. No oral agreements will be accepted. The terms on this credit application/agreement overrides all others.

By signing this credit application/agreement, the individual executing this application below on behalf of the customer, individually and personally, represents and warrants to us that:
(1) He/She is authorized to execute this application on behalf of the customer.
(2) The information set forth in this application is accurate and complete.
(3) All transactions are subject to the Terms and Conditions found on the Quala website