Credit Application

Name of Firm or Individual *

Phone number *

Fax number

Email *

Years in business *

Address *

Type of business *

Credit limit requested *

THE FOLLOWING INFORMATION MUST BE PROVIDED FOR CONSIDERATION OF EXTENDED CREDIT. ALL INFORMATION WILL BE HELD IN THE STRICTEST OF CONFIDENCE AND USED ONLY TO ESTABLISH AN OPEN ACCOUNT.

*Please attach a copy of your completed tax-exempt certificate if applicable.

Name of President / Owner *

Name of Controller *

Accounts Payable Contact *

TRADE REFERENCES

Reference #1

Business name *

Phone number *

Fax number *

Address *

Reference #2

Business name *

Phone number *

Fax number *

Address *

Reference #3

Business name *

Phone number *

Fax number *

Address *

BANK REFERENCES

Bank name *

Phone number *

Fax number *

Account Officer Name *

Account number *

We certify that all information supplied is correct. We fully understand your credit terms of N/30 and agree to payment within these terms in consideration of extended credt. We also understand that for credit limits in excess of $50,000 a copy of our most current financial statement is required.

Date *

Signed *

Title*