Credit Application

Company Name

Year Established

Mailing Address

Street Address Address Line 2 City State ZIP Code

Shipping Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Fax Number

Website

Email Address

Accounts Payable Contact

First Last

Purchasing Contact

First Last

Property

Leased
Owned

Mortgage Holder or Lesser

Mortgage Holder or Lesser Phone Number

Mortgage Holder or Lesser Address

Street Address Address Line 2 City State ZIP Code

Purchase Order Required

Yes
No

Is this company tax exempt?

Yes
No

Exempt #

Form of Business

Privately Owned
Partnership
Corporation

List all Partners

Name	Address

Bank Reference

Bank Name

Bank Phone Number

Contact Person

First Last

Address

Street Address Address Line 2 City State ZIP Code

Checking Account Number

Is this a borrowing relationship?

Yes
No

Trade References

Company 1 Name

Contact Name

First Last

Phone Number

Fax Number

Address

Street Address Address Line 2 City State ZIP Code

Company 2 Name

Contact Name

First Last

Phone Number

Fax Number

Address

Street Address Address Line 2 City State ZIP Code

Authorization

Authorized Signature

Date

Service

Solutions

Supply

Bank Reference

Trade References

Authorization