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Architectural CMU
Split-Face
Ground-Face
Polished-Face
Split-Rib
Spec-Brik®
Specialized
Standard CMU
4″ Series
6″ Series
8″ Series
10″ Series
12″ Series
Bullnose
Shapes
Screen Wall
Solid
Ready-Mix
Industrial
Light Commercial
Tilt Wall
Residential
Colored Concrete
Heavy Highway / FDOT
Curb & Gutter
Lightweight / Heavyweight
Self-Consolidating (SCC)
Flowable Fill
Retaining Wall
Trinity
Versa-Lok®
Verti-Block®
Precast
Lintels
Headers
Sills
Prestressed
Parking Stops
Splash Block
Related Materials
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Credit Application
Please fill this form in its entirety. Required fields are marked as such. Once complete, remember to click the Submit button at the bottom to securely transmit your application to our finance team.
Customer Information
Customer/Company Name
(Required)
DBA (if applicable)
Mailing Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Shipping Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email Address
(Required)
Fax Number
Entity Type
(Required)
Proprietorship
Partnership
Corporation / LLC
Social Security Number / EIN
(Required)
Tax Exempt?
(Required)
Yes
No
Year Business Started
(Required)
Number of Employees
(Required)
Annual Sales
(Required)
Professional Credit References
Provide at least two credit references. All references MUST include an email address and phone number:
(Required)
Contact Name
Phone Number
Email Address
Add
Remove
(Click the '+' at the end the row to add another entry)
Bank Information
Name of Institution
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Routing #
(Required)
Checking Account #
(Required)
Savings Account #
Company Principals
Please list your company's Officers / Principals / Partners / Directors:
(Required)
Name
Title
Address
SSN#
Add
Remove
(Click the '+' at the end the row to add another entry)
Has Customer or any officer, director or general partner of Customer ever had a prior business relationship with A-1 Block or their affiliates (A-1 Blocks Suppliers)?
(Required)
Yes
No
Please briefly explain:
(Required)
Has Customer or any officer, director or general partner of customer ever filed for Bankruptcy, been refused credit or have any outstanding liens or judgement or civil actions pending against it?
(Required)
Yes
No
Please briefly explain:
(Required)
Agreement
Credit Agreement
(Required)
I have read and agree to the terms of this Credit Agreement.
CREDIT AGREEMENT
All statements contained in this application and in the financial statements and other documentation submitted in support of the application are true and correct. Permission and authorization is hereby granted to A-1 Block and its affiliates, as well as to prior employers, professional reference, Dun & Bradstreet, banks and consumer credit services, and to state and federal government representatives, without regard to whether they are named herein, to verify, receive exchange and publish business and/or personal credit and other information as part of this application or in any other manner in connection with the ongoing application evaluation process and/or collection of any obligation arising from the business relationship, including any related guaranties or any services offered by A-1 Block. The undersigned further agree that neither A-1 Block nor anyone who has furnished A-1 Block any information concerning Customer or the undersigned or owners of the Customer shall be responsible for any claims or damages Customer or any of the undersigned may claim as resulting from said verification, receipt, or exchange.
Customer and all guarantor(s) herein agree to pay A-1 Block all amounts for all supplies, materials and services provided, shopped or sent to the Customer or at the Customer’s request within 30 (thirty) days of invoice date or as otherwise agreed to by Customer in writing. The Customer and guarantor(s) further agree to pay a finance charge of 18% (eighteen percent) per annum on any invoice not paid within 60 (sixty) or as otherwise agreed by A-1 Block in writing. Customer and guarantors agree to pay and reimburse A-1 Block with all costs and expenses associated with collection including reasonable attorneys’ fees incurred prior to litigation, during litigation and subsequent to litigation, during appeals and in any bankruptcy proceeding. Customer and guarantor(s) hereby stipulate to the jurisdiction and venue in Orange County, Florida.
A-1BLOCK MAKES NO WARRANTIES EXPRESS OR IMPLIED, WHICH EXTTEND BEYOND THE DESCRIPTION OF THE GOODS ON THE FACE OF THE RELEVANT INVOICE. FURTHER IN NO INSTANCE IS A-1 BLOCK LIABLE FOR ANY CONSEQUENIAL DAMAGES OR ANY AMOUNT IN EXCESS OF THE RELEVANT INVOICE AMOUNT.
CREDIT WILL BE GRANTED UNDER A-1 BLOCK TERMS ONLY.
Terms: Discount by the 10th of the Following Month, Net Amount Due By the 20th of the Month. Credit will be suspended on the 21st of the late month until all past due amounts are paid.
THE CUSTOMER AND GUARANTORS HEREBY IRREVOCABLY WAIVE ANY AND ALL RIGHTS THEY MAY HAVE TO A TRIAL BY JURY IN ANY JUDICIAL PROCEEDING INVOLVING ANY CLIAM RELATED TOTHIS AGREEMENT CREDIT EXTENDED HEREUNDER OR THE ATTACHED GUARANTY.
Signature
(Required)
Please type your full name followed by the last four digits of your SS# to sign.
(i.e., John Smith 0987)
Please email a copy of your sales tax exemption certificate to AR@A1BLOCK.COM for verification.
Name
This field is for validation purposes and should be left unchanged.
Search for:
Company
About Us
Products
Architectural CMU
Split-Face
Ground-Face
Polished-Face
Split-Rib
Spec-Brik®
Specialized
Standard CMU
4″ Series
6″ Series
8″ Series
10″ Series
12″ Series
Bullnose
Shapes
Screen Wall
Solid
Ready-Mix
Industrial
Light Commercial
Tilt Wall
Residential
Colored Concrete
Heavy Highway / FDOT
Curb & Gutter
Lightweight / Heavyweight
Self-Consolidating (SCC)
Flowable Fill
Retaining Wall
Trinity
Versa-Lok®
Verti-Block®
Precast
Lintels
Headers
Sills
Prestressed
Parking Stops
Splash Block
Related Materials
Bagged Good
Steel
Mortar
Masonry Accessories
Projects
Resources
Credit Application
Banking Information Request
Technical Services
Technical Literature & Documents
Safety & Environmental
Calculators
Continuing Education (AIA)
Careers
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