Application for Credit

Please provide us some information about your company. Just complete the following form and submit it to us. If you prefer to complete an Application for Credit off line and fax or mail it to us, you can download a form for this by clicking here. Any information you include is held in the strictest confidence.

Company Information

Date:
Company Name:
Business Address
Street Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
Mailing Address(if different)
Street Address:
City:
State:
Zip Code:
Parent Company name (if applicable):
Type of business started:
Years at present location:
Year business started:
Tax Exempt Certificate number:
Federal ID number:
Type of Organization:
Credit limit requested:
Has the Company been involved in any bankruptcy or insolvency proceedings?:
No Yes

Officers

First Officer
Name:
Position:
Home Address:
City:
State:
Zip Code:
Second Officer
Name:
Position:
Home Address:
City:
State:
Zip Code:

Bank References

First Bank
Bank Name:
Account Number:
Contact Person:
Phone Number:
Second Bank
Bank Name:
Account Number:
Contact Person:
Phone Number:

Trade References

First Reference
Name:
Address:
City:
State:
Phone Number:
Second Reference
Name:
Address:
City:
State:
Phone Number:
Third Reference
Name:
Address:
City:
State:
Phone Number:
Fourth Reference
Name:
Address:
City:
State:
Phone Number:

In making this application for credit, the customer agrees to pay all invoices within 30 days from date of invoice and to pay a service charge of 3 percent per month, which is an annual percentage rate of 18 percent on all overdue balances. In the event a suit is necessary to collect any amount, the customer agrees to pay the Seller's attorney's fees and costs including attorney's fees for appeal. By signing this agreement, authorization is hereby given to the vendors and banks listed herein to provide (the company) with all information necessary to establish credit with them. I hereby authorize( the company) to investigate the information presented. This account will be personally guaranteed by the persons listed below.

I agree:
Yes No
Name:
Title:
Date:

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