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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