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APPLICATION FOR CREDIT

Name of Firm or Individual 
Address
Years at this address
City
State
Zip
Area Code
Phone
TO:     (Type or rubber stamp below) HEREBY applies for credit in accordance with the terms and conditions of:
Credit Manager
Our Normal Credit Terms

The following information must be provided. It will be held in the strictest confidence.

Corporation Check here if incorporated
in the past 12 months		 Partnership Individual RESALE NUMBER:

1.
Name(s) of Principal(s)
Complete Address
Phone
2.
3.
4.
Bank
Bank Officer or Department
Bank Address
Phone

REFERENCES:

1.
Name/Address
Phone
2.
3.
4.

Check here if cash sales are okay until credit is approved.

We certify that all the information on this form is correct. We fully understand your credit terms and agree to the proper payment in consideration of extended credit.

(Signed)
(Title)
(Date)

Please do not write in the space below

VERIFICATION:

References Checked By
(   ) Credit Approved By
Reference Results
(   ) Credit Refused By
.
Date