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    General Info

    DATE //

    Firm Name

    Name of Parent Company (if subsidiary)

    Officers, Proprietors or
    Partner’s Names

     

    Street Address

    City

    State

    Zip Code

     

    Telephone Number

    Fax Number

    Email Address

     

    Nature of Business

    Year Established

    At Present Location Since
    //

     

    Sole ProprietorshipPartnershipIncorporated If Incorporated, What State?

     

    References

    Include only names of those vendors you purchase from an open account

    Reference Name #1

    Telephone Number

    Fax Number

     

    Address

    City

    State

    Zip Code

     

     

    Reference Name #2

    Telephone Number

    Fax Number

     

    Address

    City

    State

    Zip Code

     

     

    Reference Name #3

    Telephone Number

    Fax Number

     

    Address

    City

    State

    Zip Code

     

     

    Reference Name #4

    Telephone Number

    Fax Number

     

    Address

    City

    State

    Zip Code

     

     

    Banking Info

     

    Bank Name

    Account Number

     

    Address

    City

    State

    Zip Code

     

    Acknowledgement

     

    All bills which are 30 days or more past due will be subject to a service charge of 1-1/2% per month. This is equal to an annual rate of 18%.

    Signed

    Full Name of Firm

    Credit Amount Requested
    $

    Signed

    Authorized Officer

    Note: Please submit Resale Card for Tax Exempt Purchases