New Customer Information

Business name

Phone

Address

Address - line 2

City

Zip / Postal Code

Is a PO required?

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Scanned and emailed

Mailed

Accounts Payable Contact

First name

Last name

Position

Phone

Trade Reference #1

Company name

Contact name

Phone

Address

Address - line 2

City

Zip / Postal Code

Account opened since:

Credit limit:

Current balance:

Trade Reference #2

Company name

Contact name

Phone

Address

Address - line 2

City

Zip / Postal Code

Account opened since:

Credit limit:

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

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Date

Month

Day

Year