Credit Application

Todays date*:
Company Name*:
Billing Information
Address*:
City*:
Zip Code*:
State*:
Phone Number:
Fax Number:
Email*:
Names of Officers or Owners:
(1)
(2)
(3)
Ownership:	Individual Partnership Corporation
Credit References
#1:
Name:
Address:
City:
State:
Zip Code:
High credit within last 6 months:
Amount now owed:
#2:
Name:
Address:
City:
State:
Zip Code:
High credit within last 6 months:
Amount now owed:
#3:
Name:
Address:
City:
State:
Zip Code:
High credit within last 6 months:
Amount now owed:
Bank:
Anticipated Monthly Credit Requirements:
Will you accept C.O.D shipment until this application is processed?
Yes No
Enter text shown below:

DO NOT WRITE BELOW THIS LINE

credit approved rejected Rating

Billing Information