Business Name Address Owner/ManagerPhone Home Address PhoneSS# Annual Sales Volume: Years in business D & B Rated Nature of Business Person responsible for payment
Trade References: Please provide three local business references with whom you have open charge accounts:
Name Phone Address Contact
Bank Reference: Bank Name Address Acct # Phone Contact
Pending lawsuits against Company:
The name below authorizes inquiry of credit information. We further acknowledge that credit privileges, if granted, may be withdrawn at any time. Applicant attests financial responsibility, ability and willingness to pay invoices in accordance with the following terms and conditions: Deposits as required, invoices paid per terms, 2% late fees charge on past due balances.
Name E-mail Title Date
