Business Name: _________________________________
Address: _______________________________________
______________________________________________
City: _______________________ State: _____________
Zip Code: ______________ Tel. No. _________________
Owner/Manager _________________________________
How long in business ____________ D & B Rated ______
Trade References:
1.) Name: ______________________________________
Address: _______________________________________
______________________________________________
City: _______________________ State: _____________
Zip Code: ______________ Tel. No. _________________
2.) Name: ______________________________________
Address: _______________________________________
______________________________________________
City: _______________________ State: _____________
Zip Code: ______________ Tel. No. _________________
3.) Name: ______________________________________
Address: _______________________________________
______________________________________________
City: _______________________ State: _____________
Zip Code: ______________ Tel. No. _________________
4.) Name: ______________________________________
Address: _______________________________________
______________________________________________
City: _______________________ State: _____________
Zip Code: ______________ Tel. No. _________________
Bank References:
1.) Name: ______________________________________
Address: _______________________________________
______________________________________________
City: _______________________ State: _____________
Zip Code: ______________ Tel. No. _________________
2.) Name: ______________________________________
Address: _______________________________________
______________________________________________
City: _______________________ State: _____________
Zip Code: ______________ Tel. No. _________________
Credit line requested $_____________________________
Pending lawsuits against Company: __________________
The undersigned authorizes inquiry as to credit information.
We further acknowledge that credit privileges, if granted,
may be withdrawn at any time.
______________________________
[clearly print name after signature]
