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:  _________________________________