Credit Application Form

CALL: 423-622-1006

Application:
Date:*
Phone:*
Fax:
Company Name:*
Company Address:*
Name of Officer or Owner:*
Title:*
Description of Business:*
Contact person:*
At Present Location Since:*
Year Established:*
Do You Require Purchase Order Numbers?
- Yes
- No
Are You Tax Exempt?
- Yes
- No
Sales Tax #
Federal Tax ID #
Have You or any Principles filed bankruptcy?
- No
- Yes
If Yes, When?
Company or Name filed under:
Payables Manager:
Phone #
Ext #
References:
Reference 1
Bank:
Phone:
Address:
City:
ST/Zip:
Fax:
Contact Person:
Account Number:
Reference 2
Name:
Phone:
Address:
City:
ST/Zip:
Fax:
Contact Person:
Account Number:
Reference 3
Name:
Phone:
Address:
City:
ST/Zip:
Fax:
Contact Person:
Account Number:
Reference 4
Name:
Phone:
Address:
City:
ST/Zip:
Fax:
Contact Person:
Account Number:
Terms are Net 10th. A Finance Charge of 1.5% per month will be added to all unpaid balances. Credit customers Agree to pay reasonable Attorney & Collection Fees in the event Collection Process becomes necessary for delinquent accounts.
Authorized Signature required for release of credit information and agreement to terms & conditions for open account.
Name
This field is for validation purposes and should be left unchanged.