Confidential Application for Credit

Please fill in the following information.
Those marked with an (*) must be filled in.

Company Details Company Name: * DBA (if applicable) Billing Address Address 1* Address 2 City* State* Zip*

Phone*

Fax

Shipping Address Address 1 Address 2 City State Zip Phone

Fax

Accounts Payable Contact Name * Accounts Payable Phone *

Accounts Payable Fax

Company / Business Information

Company / Business Type Division
Subsidary
Branch
Wholly Owned?

Parent Company Details Name Address 1* Address 2 City* State* Zip* Federal Tax Number State Tax Number Dun & Bradstreet ID Type of Business Type of Industry Date Incorporated State Incorporated

Corporate Officer / Owner Detail

Owner / Officer #1 Name Title Home Address Address 2 City State Zip Phone

Officer #2 Name Title Home Address Address 2 City State Zip Phone

Officer #3 Name Title Home Address Address 2 City State Zip Phone

Bank / Credit References

Principal Bank Name* Address 1* Address 2 City* State* Zip* Phone Number

Fax

Representative Account Number Account Type

Credit Reference #1 Name Address 1 Address 2 City State Zip Phone Number

Fax

Email Contact Person Credit Line $

Credit Reference #2 Name Address 1 Address 2 City State Zip Phone Number

Fax

Email Contact Person Credit Line $

Credit Reference #3 Name Address 1 Address 2 City State Zip Phone Number

Fax

Email Contact Person Credit Line $

Credit Reference #4 Name Address 1 Address 2 City State Zip Phone Number

Fax

Email Contact Person Credit Line $

References with 澳博体育app下载

Have you had account with a 澳博体育app下载 Company Before? (check if yes)

If so, when?

Expected monthly freight charges : $

Do you have a 澳博体育app下载 Representative? (check if yes)

Name

If not, would you like us to assign one? (check if yes)

Disclaimer

Applicant certifies that the information above and all information accompanying this application is true and correct. Applicant authorizes 澳博体育app下载 to solicit and obtain credit information from the references above and from any other source. Applicant authorizes the references above and all other credit sources to disclose credit information to 澳博体育app下载. 澳博体育app下载 will not disclose credit information about the applicant to any other person without applicant's prior written approval. Applicant agrees to pay all charges in accordance with applicable tariffs and/or terms, which will be provided or explained by applicant's Account Specialist upon request.

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Confidential Application for Credit