Name/Address
|
Last:
First:
Middle Initial: |
Title |
|
Name of
Business: |
Tax I.D.
Number |
|
Address: |
|
|
City:
State:
ZIP:
Phone: |
|
Company Information
|
Type of
Business:
In Business Since: |
|
Legal
Form Under Which Business Operates:
Corporation ð
Partnership ð
Proprietorship ð |
|
If
Division/Subsidiary, Name of Parent
Company:
In Business Since: |
|
Name of
Company Principal Responsible for Business
Transactions:
Title: |
|
Address:
City:
State: ZIP:
Phone: |
|
Name of
Company Principal Responsible for Business Transactions:
Title: |
|
Address:
City:
State:
ZIP:
Phone: |
Bank
References
|
Institution
Name: |
Institution
Name: |
Institution
Name: |
|
|
Checking
Account #: |
Savings
Account #: |
Home
Equity Loan: |
Loan
Balance: |
|
Address: |
Address: |
Address: |
|
|
Phone: |
Phone: |
Phone: |
|
Trade References
|
|
|
|
|
Contact: |
Contact: |
Contact: |
|
Address: |
Address: |
Address: |
|
Phone: |
Phone: |
Phone: |
|
Account
Opened Since: |
Account
Opened Since: |
Account
Opened Since: |
|
Credit
Limit: |
Credit
Limit: |
Credit
Limit: |
|
Current
Balance: |
Current
Balance: |
Current
Balance: |
I hereby certify that the
information contained herein is complete and accurate. This information has been
furnished with the understanding that it is to be used to determine the amount
and conditions of the credit to be extended. Furthermore, I hereby authorize
the financial institutions listed in this credit application to release
necessary information to the company for which credit is being applied for in
order to verify the information
contained herein.
Signature: ___________________________________ Date: _________________