Credit Application

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Business Details
Business Name
Trade Name (If different)
No. of years in business
Business Address
City/State/Zip
Phone
Fax
Type of Business
State of Origin
Name of Predecessor Businesses
Contact Person Regarding Invoices
Contact Person Phone
Parent Company Details
Parent Company
Street Address
City/State/Zip
Phone
Fax
Federal ID no.
Sales Tax Exempt no.
Information on Principals

For Proprietorship or Partnership: List all Owners and/or Partners
For Corporation or Limited Liability Company: List all Officers, Directors, Members and Majority Stockholders

Name Home Address Phone no. Social Security no. Position

Have any of the companies or individuals listed above ever been a debtor in a bankruptcy proceeding?
Has any judgment ever been entered against any of the companies or principals listed above?
Are there legal actions or arbitrations pending against any of the companies or principals listed above?
Credit References (Attach separate schedule if necessary)

Primary Bank

Name
Account no.
Phone
Address
Contact Name

Other Bank

Name
Account no.
Phone
Address
Contact Name
Trade References

Reference 1

Name
Account no.
Phone
Address
Contact Name

Reference 2

Name
Account no.
Phone
Address
Contact Name

Reference 3

Name
Account no.
Phone
Address
Contact Name

Reference 4

Name
Account no.
Phone
Address
Contact Name

   
 

Memberships

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