COMPANY NAME

SHIP TO ADDRESS BILL TO ADDRESS (if different than ship to)
CITY CITY
STATE STATE
ZIP ZIP
PHONE NO. PHONE NO.
FAX NO. FAX NO.
E-MAIL ADDRESS    

SEND MY INVOICES BY:
SEND MY STATEMENTS BY:
TYPE OF OWNERSHIP:  
SS# OR FED I.D. #
GIVE YEAR BUSINESS STARTED OR YEAR OF INCORPORATION
DESCRIBE BUSINESS FUNCTION BRIEFLY

LIST NAMES OF OWNERS, PARTNERS, OFFICERS, BOOKKEEPER
TITLE HOME PHONE NO.
TITLE HOME PHONE NO.
TITLE HOME PHONE NO.

BANK REFERENCE:
BANK NAME ACCOUNT #
ADDRESS PERSON TO CONTACT
CITY    
STATE    
ZIP    
PHONE NO.    
FAX NO.    

TYPE OF ACCOUNT REQUESTED:   


AMOUNT OF CREDIT REQUESTED - MONTHLY $      
# EXP. DATE    SECURITY CODE NAME ON CARD
               

CREDIT REFERENCES (3 suppliers required):
NAME ACCOUNT # 
ADDRESS
PHONE NO. FAX NO.
 
NAME ACCOUNT # 
ADDRESS
PHONE NO. FAX NO.
 
NAME ACCOUNT # 
ADDRESS
PHONE NO. FAX NO.

INDIVIDUAL PERSONAL GUARANTY:

If the account becomes past due, applicant agrees to pay interest at the rate of 1-1/2% per month calculated on the amount past due. If the account is placed for collection, the applicant agrees to pay any collection cost incurred to collect the account balance, including reasonable attorney's fees. The undersigned warrants that the information submitted is true and correct. You are authorized to investigate the credit references listed above.

APPLICANT'S NAME  TITLE 

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