Credit Application

Billing Information

Legal Name:

Trade Name/DBA:

Billing Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Account Information

Year Business Established:

Anticipated Annual Purchases:

Federal Tax ID:

Dun & Bradstreet#:

Credit Line Requested:

Invoice

Invoice Mailed Invoice Emailed

Email address:

Contact Information

Controllers Name:

Phone:

Email:

Accounts Payable Contact:

Phone:

Email:

Purchasing Contact:

Phone:

Email:

Ownership Information

Required Info

if A or B, list names and address of Parent corp. If C, D, or E,list name(s), address(es) and social security numbers of Owner(s).

Name:

Address:

City:

State

Zip:

Name:

Address:

City:

State:

Zip:

SSN:

Bank Reference

Bank Name:

Address:

City:

State:

Zip:

Account #:

Phone:

Fax:

Trade Reference

Name &/or Dept.:

Address:

City:

State;

Zip:

Account #:

Phone:

Fax:

Email:

Name &/or Dept.:

Address:

City:

State:

Zip:

Account #:

Phone:

Fax:

Email:

Name &/or Dept.:

Address:

City:

State:

Zip:

Account #:

Phone:

Fax:

Email:

Name &/or Dept.:

Address:

City:

State:

Zip:

Account #:

Phone:

Fax:

Email:

Signature

Name:

Initial your Signature:

Title:

Date: