Business Name: _________________________________
Address: _______________________________________
City: _______________________ State: _____________ Zip Code: ______________
Tel. No. _________________ Owner/Manager _________________________________
How long in business ____________ D & B Rated ______
Trade References:
Name: ______________________________________
Address: _______________________________________
City: _______________________ State: _____________ Zip Code: ______________
Tel. No. _________________
Name: ______________________________________
Address: _______________________________________
City: _______________________ State: _____________ Zip Code: ______________
Tel. No. _________________
Name: ______________________________________
Address: _______________________________________
City: _______________________ State: _____________ Zip Code: ______________
Tel. No. _________________
Name: ______________________________________
Address: _______________________________________
City: _______________________ State: _____________ Zip Code: ______________
Tel. No. _________________
Bank References:
Name: ______________________________________
Address: _______________________________________
City: _______________________ State: _____________ Zip Code: ______________
Tel. No. _________________
Name: ______________________________________
Address: _______________________________________
City: _______________________ State: _____________ Zip Code: ______________
Tel. No. _________________
Credit line requested $_____________________________
Pending lawsuits against Company: __________________
The undersigned authorizes inquiry as to credit information. We further acknowledge that credit privileges, if granted, may be withdrawn at any time.
______________________________ [clearly print name after signature]
