CREDIT APPLICATION
Company Name: __________________________________________________________________________
Address: _________________________________________________________________________________
City: __________________ State: ____ Zip: _________ Phone: _______________ Fax: _______________
Shipping Information (if different)
Address: ______________________________________________________________
City: __________________ State: ____ Zip: _________ Phone: _______________ Fax: _______________
Federal ID: __________________________ Prof License No: ________________________ Exp: ________
Would
you like a username and password created for you to place orders
on-line? YES NO
If YES then please provide your e-mail address: ________________________________________________
Type
of Entity: Proprietorship Partnership Corporation
Other ____________________
Banking Information
Name: _______________________________ Address: _____________________________________________
City: _________________________ State: __ Zip: _______ Phone: _____________ Fax: _____________
Account Number: _____________________________ Contact Person: ________________________________
Three Trade References (Business name, Contact, phone, fax)
1. ____________________________________________________________________________________________
2. ____________________________________________________________________________________________
3. ____________________________________________________________________________________________
Estimated Monthly Volume: ____________________
I acknowledge the above information is provided solely for the purposes of extending credit to our company on your terms of Net 30 days. All information shall be kept strictly confidential and will be used for internal purposes only. To the best of our knowledge and belief, the information provided herein is accurate and may be relied upon in making your credit decision. We authorize our bank and suppliers to furnish you the information necessary to complete your evaluation of our credit history.
Signature: _________________________________ Title: _________________________ Date: ____________
(Signature must be official and have bank signature authority)