Apply for credit

CREDIT APPLICATION

Company Information:

Firm Name:

Billing Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Shipping Address: check if same as mailing address

Shipping Address:

City:

State:

Zip Code:

Phone:

In Business Since:

Type of Business:

Bank Reference:

Bank:

Telephone:

Branch:

Account#

Trade References:

1. Name:

Telephone/Fax:

2. Name:

Telephone/Fax:

3. Name:

Telephone/Fax:

Billing Information:

Accounts Payable Contact

Telephone

Do you require Purchase order numbers?

yes

Are items purchased for resale?

yes

if yes, resale #

Agreement:

I promise to pay for my purchase within the terms granted:

yes

I further assume responsibility for all bills contracted in my name at the above address and designate the following named persons as the authorized purchasing agents of the undersigned until written notice to the contrary is given:

Name:

In the event it becomes necessary for our company to incur collection costs or institute suit to collect under this agreement or any portion thereof, the undersigned promises to pay such additional collection costs and such sum as the court may adjure reasonable as attorney fees.

Firm:

Date:

Signature:

Title:

Please fax or mail signed document to:

P.O.Box 2570, Manteca, CA 95336-2570

or Fax (209) 825-1511

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