Confidential Credit Application

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Please complete the application.

Business Name *

Applicant Name *

Billing Address *

City *

State *

Zip Code *

Email Address *

Delivery Address *

City *

State *

Zip Code *

Telephone *

Fax *

Cell Phone *

Accounts Payable Contact *

Credit Amount Requested *

Federal Tax Identification Number *

Social Security Number *

Taxable (If non-taxable, a completed exemption certificate must be submitted with application.) *

Yes

Banking Reference *

Checking

Savings

Loan

Bank Name *

Account Number *

Trade Reference 1 *

Trade Reference 2 *

Trade Reference 3 *

The signatory to this Application hereby (1) acknowledges that it has been submitted in connection with a request for an extension of credit, (2) certifies that the information set forth herein is true and correct, and (3) acknowledges and agrees that the authorization, terms and other matters set forth on the reverse side are incorporated herein by reference. *

By checking this box, I ratify the use of this as an electronic representation of my signature.

Required

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
*

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