Open Account Credit Application



Business Name: _____________________________________________________

Billing Address: _____________________________________________________

_____________________________________________________

Shipping Address: _____________________________________________________

_____________________________________________________

Phone: _____________________ Fax: ________________________

Name of Parent Co. ( If Subsidiary ): ___________________________________

Type of Business: ( ) Individual ( ) Partnership ( ) Corporation

Number of Years in Business: ______

Federal Tax Number: __________________

Social Security Number: _________________

 

PROPRIETOR, PARTNERS OR OFFICERS

Name: _________________________________ Title: ______________________

Home Address: _____________________________________________________

Phone: ___________________________

Name: _________________________________ Title: ______________________

Home Address: _____________________________________________________

 

BANK REFERENCE

Name: _________________________________ Account Number: __________________

Address: ___________________________________ Phone: ______________________

 

TRADE REFERENCES

Name: _________________________________ Phone: __________________

Address: ___________________________________ Contact : ______________________

Name: _________________________________ Phone: __________________

Address: ___________________________________ Contact : ______________________

 

INDIVIDUAL RESPONSIBLE FOR PAYMENT OF ACCOUNT

Name: _________________________________ Title: ______________________

The above information is for the purpose of obtaining credit and is warranted to be true.

I/We hereby authorize the firm to whom the application is made to investigate the references listed pertaining to my/our credit and financial responsibility.

Business Name: _____________________________________________

Authorized Signature: _______________________ Date: _____________