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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