← Back to website
Print this page, fill it out by hand, and return it to HC Mining.

New Customer Application

Become a customer of HC Mining, LLC

11170 FM 1390, Scurry, TX 75158  •  (972) 474-6302  •  admin@hcminingllc.com

Please complete this application in ink. First choose your account type below, then complete the part(s) that apply to you. Required fields are marked with an asterisk (*).

Account Type: Choose One

Do you need credit terms, or will you pay at the point of sale (POS)? *
Credit TermsPoint of Sale (POS)

Part A: Business Information (all customers)

Company Information

Company Name *
Company Email *
Phone Number *
Company Website
Type of Business
In Business Since
MonthYear
Business Address
Street AddressStreet Address Line 2
CityState / ProvincePostal / Zip Code

Tax Status

Tax Exempt?
YesNo
Part B: Credit Application. Complete Part B only if you selected Credit Terms above. If you are paying at the point of sale, skip Part B and go straight to the Signature section at the end.

Part B: Credit Application (Credit Terms applicants only)

Authorized Person Information

Company Tax I.D. Number
Name *
First NameLast Name
Phone Number *
Email *
Title / Position *
Address *
Street AddressStreet Address Line 2
CityState / ProvincePostal / Zip Code

Bank References

Bank Reference 1

Institution Name *
Checking Account # *
Contact Person *
First NameLast Name
Contact Person Phone Number *
Address *
Street AddressStreet Address Line 2
CityState / ProvincePostal / Zip Code

Bank Reference 2 (optional)

Institution Name
Checking Account #
Contact Person
First NameLast Name
Contact Person Phone Number
Address
Street AddressStreet Address Line 2
CityState / ProvincePostal / Zip Code

Trade References

Trade Reference 1

Company Name *
Phone Number *
Contact Name *
First NameLast Name
Account Opened Since *
MonthYear
Current Balance
Credit Limit
Address
Street AddressStreet Address Line 2
CityState / ProvincePostal / Zip Code

Trade Reference 2 (optional)

Company Name
Phone Number
Contact Name
First NameLast Name
Account Opened Since
MonthYear
Current Balance
Credit Limit
Address
Street AddressStreet Address Line 2
CityState / ProvincePostal / Zip Code

Financial Information

Company Total Assets *
Annual Net Income *
Amount of Credit Requested *
Have you or your officers or affiliates ever filed a petition in bankruptcy?
YesNo
If so, describe:
Is your company subject to any litigation?
YesNo
If so, describe:

Signature (all customers)

Terms & Conditions and Signature

HC Mining, LLC Terms and Conditions apply to all orders. See https://www.hcminingllc.com/terms or call (972) 474-6302 for a copy. If the project is not completed by the REBID/WITHDRAW DATE, HC Mining, LLC may rebid or withdraw. Pricing depends on material availability.

By signing below you are agreeing to the HC MINING, LLC TERMS AND CONDITIONS OF SALE, and you acknowledge that all information provided is true and accurate to the best of your knowledge.

Signature *
Date

Return your completed application to HC Mining, LLC: admin@hcminingllc.com • (972) 474-6302 • 11170 FM 1390, Scurry, TX 75158