Amount of Credit Desired:

Company Name:
Street Address:       Suite/Room/Bldg:
Mailing Address:
City: State:   Zip:
Years at this location: Years in business:    Profile: Church Education Government Health Individual Insurance Manufacturer Retail Service Transportation Utilities Wholesale

Area:  Phone:  E-mail:
Area:  Fax:  

Accounts Payable Contact Name:
Accounts Payable Area Code:     Phone:   Ext:

Are purchases taxable?  yes no         if no, reason: Resale Industrial Processing Non-profit Government/Education Other
If no, exempt ID number:

Type of Business: Proprietorship Non-Profit Partnership Limited Partnerhsip Corporation Employees at your location? 1-5 6-10 7-15 16-25 26-50 51-100 101-150 151-200 201-500 501-999 1000+
Would your company like to be linked to our web site at no cost?     yes  no
Would you like to receive e-mail regarding current specials?               Yes  no

TRADE REFERENCES

Company Name:
Mailing Address:
City:  State:   Zip:
Area:  Phone:  E-mail:
Area:  Fax:  

Company Name:
Mailing Address:
City:   State:   Zip:
Area:  Phone:   E-mail:
Area:  Fax:  

Company Name:
Mailing Address:
City:   State:   Zip:
Area:  Phone:   E-mail:
Area:  Fax:  

BANK REFERENCE:
Bank Name:  
Contact Name:
City:   State:   Zip:
Area:  Phone:   E-mail:
Area:  Fax:  

I (name) , (title)
give this information for the purpose of obtaining credit, and authorize you to obtain a
credit report form any credit reporting agency.  I further authorize any bank to give
any necessary information to you which assist in your credit check.  yesno

Comments:

Note: A $25.00 charge will be added to an account balance for each returned check.
Overdue accounts will be charged 1-1/2% per month on unpaid balance.