We hereby apply for the extension of credit by your firm. The following information is submitted as a basis for your consideration of our application.
Name of Firm or Individual
Mailing Address (if different)
Established in year
Type of Business (please specify in detail)
Purchase Order Required?
Name of Person Making Application
Principal Owners or Stockholders:
NameAddressPhoneTitleSocial Security Number
We expect our monthly credit requirements to be approximately $
Address and Phone
Have you ever taken bankruptcy? If yes, when?
Principal Suppliers (Please List at Least Three)
NameAddress Phone & Fax Contact
Address & Phone of Home Office
Our Terms are Net 10th of the Month. Statements are Mailed out on the 25th of every month and are expected to be paid in full by the 10th of the following month. Any accounts not paid by the 10th of the month will be subject to a 1.5% late fee.
We certify that all information on this form is correct. We fully understand your credit terms and agree to the proper payment in consideration of extended credit.