Date:

Firm Name:   

Address:

Address 2:

City:     State:    Zip:

Please leave this field empty.

MAILING ADDRESS, IF DIFFERENT

Address 1:

Address 2:

City:  State:  Zip:

Telephone:   Fax:

Email:   Website:

Nature of Business: Years in Business:

Form of Business:

CorporationPartnershipLLCIndividual

Federal ID:     State Sales Tax Number:

 
Credit Limit Requested:   Is a Purchase Order Required?     YesNo

BANK INFORMATION

Bank Name:

Address:

Telephone:  Fax:

Account Number:   Contact Person:
 

TRADE REFERENCES

Supplier's Name:

Address:

City:  State:   Zip:

Telephone:   Fax:

Supplier's Name:

Address:

City:   State:  Zip:

Telephone:   Fax:

Supplier's Name:

  Address:

City:  State:  Zip:

Telephone:   Fax:

AUTHORIZING OFFICER, PARTNER OR OWNER:

The undersigned executes this application in his or her individual capacity and on behalf of his or her marital community, if any, and for and on behalf of the Company, in the capacity indicated; by this application, both the undersigned and the Company (1) request that an account be opened in the name of the Company (2) authorize the receipt and exchange of credit information by creditor herein, or its agent (3) agree to be liable for all the charges of the account and pay all bills when rendered (4) agree if the account is not paid when due a 1 ½% per month interest charge will be computed and added to the delinquent balance.

THIS APPLICATION AND AGREEMENT MUST BE SIGNED BY AN OFFICER, PARTNER OR PROPRIETOR OF THE FIRM TO AUTHORIZE THE OPENING OF THE ACCOUNT.

by:   Title:

by:   Title:

 
4+4=?