|
Name:
|
| Date: |
| Trade Name (If Different): |
| Billing Address: |
| Telephone Number (include Area Code): |
| Name of Individual to Contact Regarding Accounts Payable: |
| Type of Business: Year Established: |
| Organization Structure: Corporation: Proprietorship: Partnership: |
| Name of Parent Organization (If Different): |
| Address of Parent Organization (If Different): |
| TRADE REFERENCES: (Give Only Names Of Those You Buy From On Open Account) |
Reference #1:
Name: |
| Address: |
| City, State, Zip: |
| Telephone: High Credit: |
Reference #2:
Name: |
| Address: |
| City, State, Zip: |
| Telephone: High Credit: |
Reference #3:
Name: |
| Address: |
| City, State, Zip: |
| Telephone: High Credit: |
BANK REFERENCE:
Name: |
| Address: |
| City, State, Zip: |
| Telephone: Normal Balance Carried: |
The above information is offered for your consideration as a basis for the extension of credit to us on terms of NET 30 DAYS from date of invoice.
We, hereby, authorize you to contact our Trade and Bank References for the normal credit information, as may be required by your firm. |
Signature:
Date: |
| Title:
|
