Credit Application

Applicant Information:
Legal Name: ___________________________________________________________________
D/B/A (if different): _____________________________________________________________
Telephone: ________________________________

Fax: ______________________________

Website: ______________________________________________________________________
Mailing Address: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Shipping Address: ______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Other Persons Authorized To Enter Into Legal Contracts for the above named business (other
than person completing this application):
_____________________________________________________________________________
_
Authorized Purchasing Agent(s)/ Buyer(s): ___________________________________________
_____________________________________________________________________________
_
Type of Business:

Corporation

Partnership

Proprietorship

What Does Your Business Do? ____________________________________________________

_____________________________________________________________________________
_
Federal Tax ID or Social Security Number: __________________________________________
Date Business Established: ____________________ Number of Employees: _______________
Names, Titles and Addresses of Business Owners:

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
Has this Business ever been bankrupt?

Yes

No If so, date: ________________________

Amount of Credit Requested: ______________ Is your Business Tax Exempt?

Yes
No
(If the answer is yes, you must provide a sales tax exemption certificate to COMPANY NAME
If no, COMPANY NAME. will be required to charge you sales tax.)
Bank Reference:
Bank Name: ___________________________________________________________________
Bank Address: _________________________________________________________________
Contact Officer: ________________________________________________________________
Telephone: _______________________________ Fax: ________________________________
Account # 1 Number: ______________________________________

Checking

Savings

Account # 2 Number: ______________________________________

Checking

Savings

Trade References:
Business Name:_________________________________________________________________
Business Address: ______________________________________________________________
Telephone: _______________________________ Fax: ________________________________
Contact Person: _______________________________ Account Number: _________________
Business Name:_________________________________________________________________
Business Address: ______________________________________________________________
Telephone: _______________________________ Fax: ________________________________
Contact Person: _______________________________ Account Number: _________________
Business Name:_________________________________________________________________
Business Address: ______________________________________________________________

Telephone: _______________________________ Fax: ________________________________

Contact Person: _______________________________ Account Number: _________________
Credit Application Acknowledgment of Terms and Conditions:
I/We (applicant business/authorized signer) certify that the above given information is true and is
given to COMPANY NAME to induce the tender of credit to the applicant business. If the
applicant is a corporation; then the person signing this application, (whether signing person is an
officer or not) will be personally held accountable and guarantees payment for all items
purchased on credit to the above named business.
The applicant business and authorized signer authorize COMPANY NAME to make such credit
and financial investigations as it sees fit, including contacting banks, acquiring credit reports and
interviewing the stated trade references.
I/We (applicant business/authorized signer) authorize all banks, credit reporting agencies and
trade references to disclose any and all information concerning credit and financial histories of
the above named business and authorized signer.
I/We have read/acknowledge the terms and conditions stated herein and agree to all of these
terms and conditions stated.
Authorized Signature: ___________________________________________________________
Printed Name: _________________________________________________________________
Job Title: _____________________________________

Date: ________________________