Credit Application Form

Business Name

Address

Address Line 1

City

State

Zip Code

Billing Address (If Different)

Address Line 1

City

State

Zip Code

Phone

Fax

Business Contact

Business Contact Email

Accounts Payable Contact

Accounts Payable Email

Can we email you in lieu of mailing (Yes / No)

Owner / Manager Name

Owner / Manager Phone

How long in business

Federal ID #

Tax Exempt - Yes / No - If yes please include tax ID #

Dun & Bradstreet #

Company Name / Contact Name

Address

Phone / Fax #

Company Name / Contact Name

Address

Phone / Fax #

Company Name / Contact Name

Address

Phone / Fax #

Bank Name / Contact Name

Address

Phone / Fax #

Bank Name / Contact Name

Address

Phone / Fax #

Credit Line Requested

Pending Lawsuits against Company

Name / Title