Credit Application Form Name of Firm or Individual* Years at this Address*Phone*FaxAddress* Street Address City State / Province / Region ZIP / Postal Code * Corporation Partnership Individual Officers or Owners Resale Number*Date Business Started* Month Day Year Type of Business* Any Bankruptcies?* A/P Contact* Buyer's Name* Trade Reference #1*CompanyAddressPhoneFax We require 4 trade references for verification. Please provide the following: Trade Reference #2*CompanyAddressPhoneFax We require 4 trade references for verification. Please provide the following: Trade Reference #3*CompanyAddressPhoneFax We require 4 trade references for verification. Please provide the following: Bank Name* Account Number*Address Contact* Phone*Fax OUR TERMS ARE NET 30 DAYS. WE AGREE TO THESE TERMS OF PAYMENT. IF THIS FORM IS SUBMITTED ELECTRONICALLY, YOUR DIGITAL SIGNATURE WILL CONSTITUTE ACCEPTANCE OF THESE TERMS. Authorized Signature (Name)* Title* Date* Month Day Year CAPTCHANameThis field is for validation purposes and should be left unchanged.