3650 Mansell Road, Suite 400 Alpharetta, GA 30022 Tel: 770 ...



[pic]3650 Mansell Road, Suite 400 Alpharetta, GA 30022 Tel: 770-641-5909 Fax: 770-993-3446

CONFIDENTIAL CREDIT APPLICATION

Company Information:

Name: ______________________________________________________________ Website: ________________________________

Business Entity: Sole Proprietorship: ____ Partnership: ____ Corporation: ____ Other: __________________# of Employees: ______

Address: ______________________________________________________________City: __________ State: _____ ZIP: __________

Tel: ______________ Fax: ________________ Officer Name: _______________________ E-mail: ____________________________

State Incorporated: _______ Since: _____ Federal Tax ID #: _______________________Type of Business: ______________________

Billing Information:

Address: ________________________________________________________________ City: _________ State: ____ Zip: _________

Accounts Payable contact: __________________________ Tel: ______________ Fax: ____________ Email: ____________________

Name of Owners, partners, officers:

Name: ________________________ Title: ___________________Tel: ________________ Email: _____________________________

Name: ________________________ Title: ___________________Tel: ________________ Email: _____________________________

Name: ________________________ Title: ___________________Tel: ________________ Email: _____________________________

Bank References:

Name of Bank: ____________________________________________________ Tel: ____________________ Fax: _______________

Branch Address: ___________________________________________________________City: __________State: ____ Zip: ________

Type of Account: _________________________________ Account #: ___________________________________________________

Contact Person & Title: ______________________________________________Ext #: ________ Email: ________________________

Trade References:

1. Name: _______________________________ Address: _____________________________________________________________

Tel: __________________ Fax: ___________________ Email: _____________________________________How Long: ___________

2. Name: _______________________________ Address: _____________________________________________________________

Tel: _________________ Fax: ___________________ Email: ______________________________________How Long: ___________

3. Name: _______________________________ Address: _____________________________________________________________

Tel: __________________ Fax: ___________________ Email: _____________________________________How Long: ___________

……………………………………………………………………………………………………………………………………………….……………………………………………………………..

READ before Signing:

I, the undersigned, warrant the financial information above to be true, correct and complete to the best of my knowledge and hereby authorize any credit investigation needed for verification.

Print Name: _________________________________________________________ Title: ____________________________________

MUST be Legible MUST be Legible

Signature: ______________________________________________________________ Date_________________________________

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