Credit Application

Bill To Information
Company:
Division:
Address:
City:
State:	Zip:
Phone:	Fax:
Ship To Information
Company:
Attention:
Address:
City:
State:	Zip:
Phone:	Fax:
General Business Information
DUNS #:
Type of Business:
D.B.A.:       Individual:       Partnership:       Corporation:
Years in Business:
Year of Incorporation:       State of Incorporation:
Sales Tax / Use Exempt:      Yes        No
If Exempt, enter Certificate #:
Officer:	Title:
Officer:	Title:
Accounts Payable Contact Name:
Accounts Payable Phone #:
Bank Reference
Bank Name:
Officer:
City:
State:	Zip:
Phone:	Fax:
Checking Account #:
Savings Account #:
Other:
Business Credit Reference
Credit Reference #1
Company:
Address:
City:
State:	Zip:
Phone:	Fax:
Credit Reference #2
Company:
Address:
City:
State:	Zip:
Phone:	Fax:
Credit Reference #3
Company:
Address:
City:
State:	Zip:
Phone:	Fax:
We certify that all the information on this form is correct; and that we fully understand your credit terms and agree to the proper payment in consideration of extended credit.
Your Name:	Title:
E-Mail:	Phone:

 

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