Credit Application

Application Information
Company Name
Number of years in business under this name		Number of years at this location
Phone
Fax
Mailing Address
City
State
Zip Code
Type of Business
Taxable?	Yes No
Accounts Payable Contact
Contact's Phone
Extension

Ownership
Type Ownership	Individual Partnership Corporation
Federal Tax ID #
Principal #1
Title
Principal #2
Title
Principal #3
Title

Trade References
Company #1
Address
Contact
Phone
Extension
Company #2
Address
Contact
Phone
Extension
Company #3
Address
Contact
Phone
Extension

Bank Reference
Bank Name
Account Number
Address
City
State
Zip
Contact
Phone
Extension

Applicant Information
Applicant Name
Title
Phone
Extension
Date
Signature (if mailed)	_______________________________________