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GENERAL INFORMATION

Company Name:  
Physical Address:   City:  
State:   Zip (Postal) Code:  
Mailing Address:   City:  
State:   Zip (Postal) Code:   
Telephone:   Fax:   
Type of Organization:   Federal ID:   
Tax Status - Exempt:   (If yes, please provide exempt certificate.)



PRINCIPAL OWNERS AND EXECUTIVES

Owner Name:   Title:  
Home Address:   City:  
State:   Zip (Postal) Code:  
Email:   Type of Business:  
Owner Name:   Title:  
Home Address:   City:  
State:   Zip (Postal) Code:  
Email:   Type of Business:  
Accounts Payable Manager:   Manager Email:  
Purchasing Agent:   Agent Email:  



BUSINESS REFERENCES

Company Name:   Contact Name:  
Address:   City:  
State:   Zip (Postal) Code:  
Telephone:   Fax:  
Company Name:   Contact Name:  
Address:   City:  
State:   Zip (Postal) Code:  
Telephone:   Fax:  
Company Name:   Contact Name:  
Address:   City:  
State:   Zip (Postal) Code:  
Telephone:   Fax:  



BANK REFERENCES

Bank Name:   Contact Name:  
Address:   City:  
State:   Zip (Postal) Code:  
Telephone:   Fax:  
Account Number:     


If this account is placed in the hands of a bonded collection agency or attorney for collection, the undersigned shall pay an amount equal to 30% of the unpaid principle and interest as a collection fee, which amount the undersigned agrees is reasonable.

This is to certify that I am a principal in the above named business and in consideration for the extension of credit, I do personally guarantee payment of any and all invoices which remain unpaid and if the application for credit is a corporation, the undersigned, in addition to personally guaranteeing payment, represents that he/she/they are authorized to make this application on behalf of the aforementioned corporation.

Printed Name:  
Title:  
Email:  


 
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