APPLICATION FOR CREDIT
Accounting Contact Name:
Accounting Phone Number:
Credit Line Requested:
Legal Name for Billing:
Phone Number:
Fax Number:
Billing Address:
Parent/Hdqtr Name:
Company Type
Parent/Hdqtr Address:
Please List Owners, Partners, Officers Name, Title and Addresses:
1.
2.
3.
TRADE REFERENCES:
1.
2.
Company Name:
Company Address:
Company Phone:
Company Fax:
Company Name:
Company Address:
Company Phone:
Company Fax:
3.
Company Name:
Company Address:
Company Phone:
Company Fax:
BANK REFERENCES:
Bank Name:
Bank Address:
Bank Phone:
Bank Fax:
Account No.:
Contact Name.:
Have you ever applied for open line of credit with us before?
Do all orders require a purchase order?
Accounts requesting a credit line over $1,000.00 may be required to furnish a financial statement.
THE ABOVE INFORMATION IS FOR THE PURPOSE OF OBTAINING COMMERCIAL CREDIT AND IS WARRANTED TO BE TRUE, CORRECT AND COMPLETE.  CREDITOR, ITS AGENTS, OR ANY CREDIT BUREAU EMPLOYED BY CREDITOR IS HEREBY EXPRESSLY AUTHORIZED TO INVESTIGATE THE REFERENCES HEREIN LISTED OR OTHER DATA OBTAINED FROM APPLICANT OR FROM ANY OTHER PERSONS PERTAINING TO APPLICANTS CREDIT RESPONSIBILITY.  APPLICANT ALSO AUTHORIZES THE ABOVE BANK TO RELEASE INFORMATION REGARDING HIS CHECKING ACCOUNT BALANCES AND LOAN RELATIONSHIPS.  APPLICANT'S SIGNATURE ATTESTS TO APPLICANT'S FINANCIAL RESPONSIBILITY, ABILITY TO PAY CREDITOR'S INVOICES IN ACCORDANCE WITH CREDITOR'S TERMS.  APPLICANT AGREES TO PAY A SERVICE CHARGE AS SPECIFIED IN THE TERMS AND CONDITIONS OF SALE ON THE UNPAID PAST DUE BALANCE.  APPLICANT AGREES TO PAY FOR ALL COST OF COLLECTION, INCLUDING REASONABLE ATTORNEY FEES, COURT COSTS AND COLLECTION AGENCY FEES FOR PAST DUE ACCOUNT.  SENDING THIS APPLICATION THROUGH INTERNET, EMAIL OR ANY OTHER FORM OF E-COMMERCE CONSTITUTES ACCEPTANCE BY THE COMPANY WITHOUT WRITTEN SIGNATURE.

Authorized Name:
Title:
Date:
E-Mail address: