Name of Business *

Address 1 *

Address 2

City *

State *

Zip *

Type of Organization Corporation
Partnership
Individual
*

No. Years in Business *

No. Years in this Location *

Contact Name *

Contact Phone *

Contact Position

Name of Your Bank *

Bank Address 1 *

Bank Address 2

Bank City *

Bank State *

Bank Zip *

Bank Acct. # *

Bank Contact *

1. Name *

Address *

Phone # *

2. Name *

Address *

Phone # *

3. Name *

Address *

Phone # *

Are You Paying Your Bills Within Terms? Yes
No

Estimate of Annual Sales Volume *

Estimate of Business Asset Value *

What Dollar Amount of Credit Does Your Company Require? *

I certify that the above information is true and correct. I agree that in return for the privelege of buying on open account, if I do not pay within terms, I will pay 1-1/2% per month financing charges (18% per annum) on past due invoices and any collection cost that may arise. *

Please enter the following text: