Credit Application

Date

Complete Legal Name

Street Address

City

Zip

State --- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Country

Billing Address

Email

Phone

Fax

Business Structure: Corporation - Publicly Held Corporation - Closely Held Partnership - General Partnership - Limited Sole Proprietorship

Federal ID #

Trade References: ALL three spaces must be filled in with current open account creditors that allow your firm to purchase $1,000.00 or more, within the last 12 months.

Confirmation of Information Accuracy and Release of Authority to Verify. The undersigned, for the procuring and establishing credit from time to time with Supplier to permit the above named customer to become indebted to Supplier for purchase of goods, materials, and/or services, furnishes the above business and personal credit information. The undersigned, jointly and individually, certify that all information in this Credit Application is complete, factual and correct, and understands the Supplier will rely on the accuracy of this information for any credit that may be extended. Supplier is hereby expressly authorized to contact any parties listed herein and to verify any information contained in this Credit Application. The undersigned hereby waives any privacy of credit information rights or regulations. If any representations made on the Application prove to be untrue, the undersigned agrees that all obligations of the above named customer to, or held by, Supplier shall immediately become due and fully payable without demand or notice, and the undersigned further expressly agrees to assume personal liability for all obligations of said customer to Supplier. The undersigned hereby acknowledges receipt of a copy of this Credit Application.

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