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Credit Application form

Date:*

COMPANY INFORMATION

Corporate or

company name: *

Is your company Incorporated? Yes No

If yes, which state?

Fed ID: *

Bill to address: *

City: *

State: *

Zip:

Phone:

Ship to address (if different from above):

City:

State: *

Zip:

Phone:

Are you sales Taxable? Yes No

If no please provide exemption certificate:

Number of years under present ownership:

Nature of business:

OWNERS, PRINCIPALS, and OFFICERS

Name

Address

Phone

Have you or any other Owners/Partners or Officers with the Co. listed above filed bankruptcy in the past five years?

Yes No

If yes please list details:

Controller name:

Phone:

Controller Email: *

Controller Fax:

Accounts payable contact:

Phone:

Accounts payable Email:

Accounts payable Fax:

Bank Name: *

Address: *

Contact Name: *

Phone:

Acct #:

Duns #:

Checking:

Loan:

Please provide 5 Company Trade References

Name, Address, Contact Person, Telephone, Fax # and Account #

Signature of corporate officer: *

Date: *

Printed name:

Title: *

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