CREDIT APPLICATION

Print out this form, fill it out and fax it to 586-779-0876.

You may also mail it to us at 27941 Groesbeck Hwys., Roseville, MI 48066

COMPANY INFORMATION
Company Name:
Bill To Address:

Phone:
Number of years in business:

Ship To Address:

Fax:

Email:
D & B number:

PRINCIPAL CONTACTS
General Manager:
Purchase Manager:
Controller:
Salse Manager:

CREDIT REFERENCES
Company & Contact Name

Address

Phone

1.
2.
3.
Bank Name:

Account Number:

Address:

Officer:

Credit Line Requested:

Estimated Monthly Purchases:

The above information is provided for the purpose of extending credit to our company on your terms of net 30 days. To the best of out knowlede and
beliedt, this information is accurate and may be relied upin in making your credit decision. We authorize our bank and suppliers to furnish you any
information necessary to complete your evaluation of our credit history.

Name:

Title:

Date: