APPLICATION FOR OPEN ACCOUNT CREDIT
FOR STOCKING DEALERS
(Please Fill Out Completely and Legibly)
COMPANY NAME:
________________________________
D/B/A:
___________________________________________
BILLING ADDRESS:
______________________________________________________________________
______________________________________________________________________
SHIPPING ADDRESS:
______________________________________________________________________
______________________________________________________________________
PHONE NUMBER:
___________________________
FAX NUMBER:
______________________________
OWNER(S) NAME:
___________________________
SALES TAX NUMBER:
_______________________
BUYER:
____________________________________
STORE SIZE:
____________________________ SQ. FT.
BOOKKEEPER:
______________________________
NUMBER OF EMPLOYEES: ________________
NUMBER OF YEARS IN BUSINESS UNDER CURRENT
OWNER: ___________
PURCHASE SUBJECT TO SALES TAX? [
] YES [ ] NO
PURCHASE ORDERS REQUIRED? [ ] YES
[ ] NO
LINE OF CREDIT REQUESTED: $____________________
TYPE OF COMPANY: [
] SOLE PROPRIETORSHIP [ ] PRIVATE CORP.
[ ] PARTNERSHIP [
] PUBLIC CORP.
[ ] OTHER
___________________________
TYPE OF BUSINESS:
[ ] ANTIQUES [ ]
CATALOG [ ]
FLORIST
[ ] GIFTS [ ] DEPARTMENT
[ ] OTHER
___________________________
BANK BRANCH:
__________________________________
BANK CONTACT:
_________________________________
BANK ADDRESS:
_________________________________
PHONE NUMBER:
_________________________________
FAX NUMBER:
____________________________________
ACCOUNT NUMBER:
______________________________
TRADE REFERENCES
(Please give complete addresses and account
number(s))
COMPANY:
________________________________________
ADDRESS: _________________________________________
PHONE:
_________________ FAX: __________________
ACCOUNT NUMBER:
________________________________
COMPANY:
________________________________________
ADDRESS:
_________________________________________
PHONE: _________________ FAX:
__________________
ACCOUNT NUMBER:
________________________________
COMPANY:
________________________________________
ADDRESS:
_________________________________________
PHONE:
_________________ FAX: __________________
ACCOUNT NUMBER:
________________________________
COMPANY:
________________________________________
ADDRESS:
_________________________________________
PHONE:
_________________ FAX: __________________
ACCOUNT NUMBER:
________________________________
To the best of my knowledge the above facts are
represented as true. I am aware that
falsification of any of this information may result in denial of credit by
____________
_________________________ Inc. My signature below indicates my permission
for ___________________________________ Inc., to obtain credit information from
the sources I have referenced, including any external credit reporting source,
and any consumer credit agency. I
understand that interest will be charged on all past due balances at a rate of
________% per month.
________________________________________________
AUTHORIZED INDIVIDUAL (Please Print)
________________________________________________
SIGNATURE
____________________________
DATE