Company Name (required)
Street Address
Billing Address
Phone
Fax
Federal ID #
Dun & Bradstreet #
Type of Business ---ProprietorshipPartnershipCorporation
Date Business Started
Does your company require a purchase order with each purchase? (required) Yes No
Accounts Payable Contact
Accounts Payable Phone
Amount of Credit Requested (required)
Is your Company currently or has it ever been in bankruptcy? (required) Yes No
If yes...
When?
Where?
How many times?
Under what name?
Name, Title and Address of Principles (If Corporation, List Officers)
Bank Name
Bank Address
Bank Officer (Contact)
Bank Officer (Phone)
Bank Officer (Fax)
Trade Reference (address, Phone and Fax Numbers)
