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Credit Application Form

Credit Information
DATE:   ( mm/dd/yy )
COMPANY NAME:
BILLING ADDRESS: Line 1:
Line 2:
CITY:
STATE:
ZIP CODE:
COUNTRY:
SHIP ADDRESS: Line 1:
Line 2:
CITY:
STATE:
ZIP CODE:
COUNTRY:
TELEPHONE #:  ( XXX ) XXX - XXXX
FAX #:
RESALE #
%:
PRINCIPAL OWNER NAME:
PURCHASE AGENT NAME:
ACCOUNTS PAYABLE NAME:
BANKING INFORMATION
BANK NAME:
TELEPHONE #:
ACCOUNT #:
TRADE REFERENCE INFORMATION
COMPANY: 1
ADDRESS LINE 1:
ADDRESS LINE 2:
CITY:
STATE:
ZIP CODE:
COUNTRY:
PHONE #:
FAX #:
COMPANY: 2
ADDRESS LINE 1:
ADDRESS LINE 2:
CITY:
STATE:
ZIP CODE:
COUNTRY:
PHONE #:
FAX #: