Credit Application

Complete Legal Name:*
Address:*
City:*
State:*
Zip:*
Telephone:*
Billing Address:*
Billing City:*
Billing Zip:*
Describe your work:*
Business Structure:*  Corp- Public Corp- Closely Held Partnership Sole Proprietorship
If Incorporated, date of incorporation:
If Incorporated, state of incorporation:
Years in Business:
PO's Accepted:  Yes No
Credit limit requested::
Bank Name:*
Bank Address:*
Bank City:*
Bank State:*
Bank Zip:*
Bank Phone:*
Officer Name:*
Checking Account Number:*
Trade References

Firm #1

Firm Name:
Firm Address:
Firm City:
Firm State:
Contact Name:
Contact Number:

Firm #2

Firm Name:
Firm Address:
Firm City:
Firm State:
Contact Name:
Contact Number:

Firm #3

Firm Name:
Firm Address:
Firm City:
Firm State:
Contact Name:
Contact Number:
Company Principals Responsible for Business Transactions

Principal #1

Name:
Home Address (Not required for corp.):
Home City (Not required for corp.):
Home State (Not required for corp.):
Position:
SSN or FEIN (Not required for corp.):

Principal #2

Name:
Home Address (Not required for corp.):
Home City (Not required for corp.):
Home State (Not required for corp.):
Position:
SSN or FEIN (Not required for corp.):

Principal #3

Name:
Home Address (Not required for corp.):
Home City (Not required for corp.):
Home State (Not required for corp.):
Position:
SSN or FEIN (Not required for corp.):
Purchase Agreement

Terms: Due and payable in full within 30 days of invoice
Late Payment: Past due amounts are subject to late payment service charges of 1.5% per month, which is an annual rate of 18%
Receipt of Copy: Customer hereby acknowledges the receipr of a copy of this agreement at the time of its execution.

Credit Information

The information contained herein is a request for the extension of credit for commercial business use only. By checking below, we certify that the information contained herein is correct and we authorize the named Creditor to obtain written or verbal credit reports from the credit references listed. The Creditor is hereby authorized to deliver goods at our request and charge our account. This authorization shall continue until written notice to the contrary is given.