Company Name: ___________________________________________ Contact: __________________________
Billing Address: _____________________________________________________________________________

City: _______________________________________________ State: __________________ Zip: ___________

Shipping Address:____________________________________________________________________________

City: _______________________________________________ State: __________________ Zip: ___________
Phone No. _______________________ Fax No. _____________________ E-mail: _______________________
 

Check One:  ›  Proprietor   ›  Partnership  ›  Corporation    Date Established: _____________

Tax Status: ____________ Tax ID #: ____________________ Please fax copy of tax certificate with application.

Name of Principals                  Address                          City, State  Zip                          Phone
________________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Trade References:

1. Company: ______________________________________________________________________________
Address:___________________________________________________________________________________

City: ______________________________________________ State: __________________ Zip: ____________
Phone No. _________________________ Fax No. ____________________ E-mail: ______________________

2. Company: _______________________________________________________________________________
Address:___________________________________________________________________________________

City: ______________________________________________ State: __________________ Zip: ____________
Phone No. _________________________ Fax No. ____________________ E-mail: ______________________

3. Company: _______________________________________________________________________________
Address:___________________________________________________________________________________

City: ______________________________________________ State: __________________ Zip: ____________
Phone No. _________________________ Fax No. _____________________ E-mail: _____________________

Bank Reference:

Name: ______________________________________________________ Contact Person: _________________
Address:___________________________________________________________________________________

City: ______________________________________________ State: __________________ Zip: ____________
Phone No. ________________________ Fax No. ______________________ E-mail: _____________________

The above information is for the purpose of obtaining credit and is warranted to be true.  I/We authorize you to
investigate the references listed pertaining to my/our credit responsibility.
Name: ______________________________________________ Title: _______________________________

Signature: ____________________________________________ Date: _______________________________