OPEN ACCOUNT CREDIT APPLICATION
FIRM NAME:
_________________________________
PHONE:
_____________________________________
FAX:
________________________________________
BILLING ADDRESS:
___________________________________________________
CITY, STATE, ZIP:
_____________________________________________________
SHIPPING ADDRESS:
__________________________________________________
CITY, STATE, ZIP:
_____________________________________________________
( ) Individual ( ) Partnership (
) Corporation
NAME OR PARENT CO. ( If Subsidiary )
___________________________________
TYPE OF BUSINESS:
_________________________ YRS. IN BUSINESS: ______
FEDERAL TAX NO.:
___________________________________________________
SOCIAL SECURITY NO.: _______________________________________________
PROPRIETOR, PARTNERS OR OFFICERS
NAME:
_________________________________ TITLE: ______________________
HOME ADDRESS:
_____________________________________________________
PHONE NUMBER:
___________________________
NAME:
_________________________________ TITLE: ______________________
HOME ADDRESS:
_____________________________________________________
PHONE NUMBER:
___________________________
NAME: _________________________________
TITLE: ______________________
HOME ADDRESS:
_____________________________________________________
PHONE NUMBER:
___________________________
INDIVIDUAL RESPONSIBLE FOR PAYMENT OF ACCOUNT
NAME:
_________________________________ TITLE: ______________________
BANK REFERENCE
NAME:
_________________________________ ACCT. NO.: __________________
ADDRESS:
_______________________________ PHONE:
____________________
CITY/STATE/ZIP:
_______________________ CONTACT:
___________________
TRADE REFERENCES
NAME:
__________________________________ PHONE: ____________________
ADDRESS:
____________________________ CONTACT:
____________________
NAME:
__________________________________ PHONE: ____________________
ADDRESS:
____________________________ CONTACT:
____________________
NAME:
__________________________________ PHONE: ____________________
ADDRESS:
____________________________ CONTACT:
____________________
Applicants signature attests financial
responsibility, ability and willingness to pay our invoices in accordance with
terms stated below. If any suit or
legal action is instituted in connection with any controversy arising out of
the estimate, proposal, or any work authorized in connection with same, the
prevailing party shall be entitled to recover, in addition to the court costs
and disbursements, such sum as the court may adjudge reasonable as attorney
fees.
The above information is for the purpose of
obtaining credit and is warranted to be true.
I/We hereby authorize the firm to whom the
application is made to investigate the references listed pertaining to my/our
credit and financial responsibility.
COMPANY NAME:
_____________________________________________
AUTHORIZED SIGNATURE: ________________________________
POSITION:
_________________________________