mg10.21.09.002
Net 30 Credit Application
PLEASE COMPLETE IN FULL – INCOMPLETE AND/OR INACCURATE APPLICAIONS MAY DELAY PROCESSING.
Customer Number _________________
Company Information
Company Name _____________________________________________
Billing Address ______________________________________________
Shipping Address ____________________________________________
City ____________________ State _________ Zip _________________
Phone ( ) __________________ Fax ( ) ___________________
D/B/A _____________________________________________________
Former Business Address (If less than 5 yrs) ______________________
__________________________________________________________
Name of Landlord if Building not owned __________________________
Address/ Phone number _______________________/_______________
Federal I.D. ______________ Certificate of resell #_______________
Type of Business _______________ Date Established ______________
Email Address ______________________________________________
Does State, County, or City Require a License? YES NO
(Attach copy of original)
No. Of Employees _____ Est. Annual Sales $ _____________________
A/P Contact ________________________________________________
If Yes License #_____________________________________
Legal Status (circle one)
Sole Proprietor Partnership Corporation Parent Company (if applicable) ______________________
Principals
Principal: ________________________________________________________________________________________
(Name) (Title) (Home Address/Tel.)
Principal: _________________________________________________________________________________________
(Name) (Title) (Home Address/Tel.)
Trade/ Vendor References
(References supplying product or services who have granted credit terms. Do not list utilities or personal references.)
Firm Name Phone # Fax # Email Address
Payment
Terms
Bank Information
____________________ _____________________________________________ _________________________________
(Bank Name) (Street Address) (City/State/Zip Code)