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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
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  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