Customer Credit Application

Business Information

* Business Name

* Email Address

* Phone Number

* Mobile Number

* FAX Number

* Billing Address

* City

* State

* Zip Code

Physical Address

* City

* State

* Zip Code

Shipping Address

* City

* State

* Zip Code

* Federal Tax ID

* Corporation Type

* Starting Date of Business

* If Incorporated: Date and State

* Corp. Article #

* State Resale #

* Dunn and Bradstreet #

* Purchasing Contact

* Phone Number

* Email Address

* A/P Contact

* Phone Number

* Email Address

Please send copy of state resale certificate

Bank Reference

* Bank Name

* Bank Account #

* Date account opened

* Contact Name

* Phone Number

* FAX Number

Trade References (please fill in fax numbers)

* Company Name

* Name

* Phone #

* FAX #

* Email Address

* Average Balance

* Credit Line

* Terms

* Indicates Response Required

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