Confidential Credit Application
Business Name Phone
Mailing Address         FAX  
        Federal ID#
Shipping Address Email  
        Yr. Established:  
In the past five years have you operated under other names? Yes ____ No ____     If YES, what name? __________________   
Do you have an established line of credit for your business? Yes ____ No ____     If YES, in which *state? ________________
Have you pledged collateral for your borrowing? Yes ____ No ____       *Required
Owner(s) or Officer's
Organization:     Proprietorship______     Corporation_____     Partnership_____
1 Name     Address       Phone  
2 Name     Address       Phone  
Trade Reference Only:  (Please furnish COMPLETE information)
1 Name Phone
Address             FAX  
2 Name Phone  
Address             FAX  
3 Name Phone  
Address             FAX  
4 Name Phone  
Address             FAX  
Bank Reference
1 Name       Acct #     Phone  
Address             FAX  
2 Name       Acct #     Phone  
Address             FAX  
Have you ever filed Bankruptcy? Yes ____   No ____ If yes, please enclose details.
Text Box: Fax Communication Consent Availability list is sent twice a month unless notified. ______ FAX _______ Regular Mail ______ Email _______ No Thank You We will call when we need one Buyer:_______________________________ *Signature Required
Text Box: Buyer agrees that Buyer has read the Terms and Conditions on the reverse side of this sheet and agrees they are part of this credit agreement. Buyer further agrees to be bound by the Terms and Conditions of this credit agreement in regard to all orders placed with Seller: Buyer: ______________________________ *Signature Required Date: ______________________________ Text Box: Release to Creditors Everything I have stated in this credit application is true and correct to the best of my knowledge. I understand that you will retain this application whether or not credit is approved. I, hereby authorize you to verify all information contained in this application. Buyer: ______________________________ *Signature Required
Please Print and fax to us at  (503) 628-2257