NAME/ADDRESS |
Last
First
MI
Title
|
Name
of Business
Tax
ID Number
|
Address
|
City
State
Zip
Phone
FAX
|
COMPANY
INFORMATION |
Type
of Business
|
Legal
Form Under Which Business Operates: Corporation
Partnership
Proprietorship
|
If
Division/Subsidiary, Name of Parent Company:
|
TRADE
REFERENCES |
1.
Company Name
Contact Name
|
Address
|
City
State
Zip
Phone
FAX
|
Date
Opened
High Credit
Current Balance
|
2. Company Name Contact Name |
Address
|
City
State
Zip
Phone
FAX
|
Date
Opened
High Credit
Current Balance
|
3. Company Name Contact Name |
Address
|
City
State
Zip
Phone
FAX
|
Date
Opened
High Credit
Current Balance
|
4. Company Name Contact Name |
Address
|
City
State
Zip
Phone
FAX
|
Date
Opened
High Credit
Current Balance
|
BANK
REFERENCE |
Institution
Name
Account Number
|
Address
|
City
State
Zip
Phone
FAX
|
STATEMENT
OF ACCURACY AND PERMISSION TO VERIFY |
I
hereby certify that the information contained in this credit application
is complete and accurate. This information has been furnished with
the understanding that it is to be used to determine the amount
and conditions of the credit to be extended. Furthermore, I hereby
authorize the financial institution listed in this credit application
to release necessary information to the company for which credit
is being applied for in order to verify the information contained
herein. |
I
agree with the terms above
Name
Date
|
12318
Lower Azusa Road, Arcadia, CA 91106-5872 • Ph: 626-443-6433
• Fax: 626-443-1435 |
