Form Page: Credit

CUSTOMER CREDIT APPLICATION

Company Name:

Address:

City / State / Zip:

Business Fax

Business Phone:

Email Address:

Acct. Payable Contact:

Exp.

Credit Card No:

Ownership Information:

President / Owner:

Address:

City / state / Zip:

Trade References:

Name:

Phone:

Address:

Fax:

City / state / Zip:

Name:

Phone:

Address:

Fax:

City / state / Zip:

Name:

Phone:

Address:

Fax:

City / state / Zip:

I, the undersigned, agree to pay within the specified credit terms of net 15 days should
credit be extended to me or my company. I further agree to be directlyresonsible for
payment of all invoices charged to my account within this designated time period.

Date

Signature

Title

Print Name

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