Credit Application
Fax To: 1-877-696-7329 || PRINT
Company Information
Your Name:
Title:
Company Name:
Phone Number:  (              ) Fax Number:  (              )
Email Address:
Organization Type:  __ Corporation __ Sole Proprietorship __ Partnership __ Other
Year Established:
# Employees:
Tax Status:  __ Taxable __ Non-Taxable
Billing Address
Address1:
Address2:
City, State, Zip:
Shipping Address (leave blank if same as billing address)
Address1:
Address2:
City, State, Zip:
Credit Information
Credit/Trade Reference 1
Company Name:
Address:
City, State, Zip:
Phone Number:  (              ) Fax Number:  (              )
Email Address:
Account Type:
Credit/Trade Reference 2
Company Name:
Address:
City, State, Zip:
Phone Number:  (              ) Fax Number:  (              )
Email Address:
Account Type:
Credit/Trade Reference 3
Company Name:
Address:
City, State, Zip:
Phone Number:  (              ) Fax Number:  (              )
Email Address:
Account Type:
Bank Reference
Bank Name:
Address:
City, State, Zip:
Contact Name:
Phone Number:  (              )
By submitting this form, we warrant the information provided to be true. I, an authorized officer, grant permission to investigate the references, including commercial and consumer credit checks. I agree to pay all invoices within the terms of sale and understand that a $25.00 service charge applies to all dishonored checks. A service charge of 18% per year or up to the legal rates, will be imposed upon the accrued, unpaid balance of any bill not paid within terms. If the account is placed with an attorney, whether a lawsuit is filed or otherwise, or if any services are required to protect our interest, we agree to pay all costs and suit fees, including a reasonable attorney's fee on the principal and service charges.
Authorized Signature: _____________________________________________ Date: ____________________