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    General Info DATE //
    Firm Name
    Name of Parent Company (if subsidiary)

    Officers, Proprietors or
    Partner’s Names

      Street Address
    City
    State
    Zip Code
      Telephone Number
    Fax Number
    Email Address
      Nature of Business
    Year Established
    At Present Location Since
    //
      Sole ProprietorshipPartnershipIncorporated If Incorporated, What State?

     

    References Include only names of those vendors you purchase from an open account
    Reference Name #1
    Telephone Number
    Fax Number
      Address
    City
    State
    Zip Code
     
      Reference Name #2
    Telephone Number
    Fax Number
      Address
    City
    State
    Zip Code
     
      Reference Name #3
    Telephone Number
    Fax Number
      Address
    City
    State
    Zip Code
     
      Reference Name #4
    Telephone Number
    Fax Number
      Address
    City
    State
    Zip Code
     

     

    Banking Info
      Bank Name
    Account Number
      Address
    City
    State
    Zip Code

     

    Acknowledgement
      All bills which are 30 days or more past due will be subject to a service charge of 1-1/2% per month. This is equal to an annual rate of 18%.
    Signed Full Name of Firm
    Credit Amount Requested
    $
    Signed Authorized Officer
    Note: Please submit Resale Card for Tax Exempt Purchases