Business Charge Application

APPLICATION INFORMATION

Company Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Fax

Years in Business*

Person Making Application*

Title*

TYPE OF OWNERSHIP

Ownership*

Corporation
Partnership
Sole Proprietorship

Federal ID#

Social Security #

Handling

Tax Exempt (attach copy of Federal exemption letter
Resale (attach copy of Certificate of Resale)

OWNERSHIP:

Name(s) of Officer(s) and Title*

Officer Address*

Street Address City State / Province / Region ZIP / Postal Code

Officer Phone #*

Officer Phone #

Name(s) of Officer(s) and Title*

Officer Address*

Street Address City State / Province / Region ZIP / Postal Code

Officer Phone #*

Officer Phone #

FINANCIAL

Bank

Bank Address

Bank Phone #

Bank Officer or Department

Bank Officer or Department Phone #

BUSINESS REFERENCES

Business Name

Complete Address

Business Phone #

Business Fax #

Business Name

Complete Address

Business Phone #

Business Fax #

Business Name

Complete Address

Business Phone #

Business Fax #

Do you Require a Purchase Order*

Yes
No

Authorized Users

No restrictions to charge will be placed on this account unless a specific list of authorized users is provided. Any changes to the list must be submitted in writing.

I/We certify that all the information on this form is correct. I/we fully understand your credit terms and agree to the proper payment in consideration of extended credit. Furthermore, I/we approve of your obtaining information from the above references and a credit report on my company or if not a corporation, a report on me/us personally. If you update, renew, or extend my line of credit, you may request a new report without notice.

Name (Printed)

Signature

You will be asked to sign this form upon approval.

Title

Date