Credit Application


Revised: 10/21/2010

Company Information

Full Legal Name/Business Entity
Phone Number
Fax Number
Doing Business As (DBA)
Billing Address
City
State
Zip
Proprietorship    Partnership    Limited Partnership    Limited Liability Company    Corporation    Other:
Number of Employees
Year Business Established
Annual Sales
Type of Business
Federal Tax ID (if incorporated)
State of Incorporation
Federal Tax Exemption Number (if exempt)
Email Adress(es)
Credit Card Number
Expiration Date
Card Holder (backup payment method)

Owner or Corporate Officer Information (please list two (2) minimum)

Full Name (including middle initial)
Title
Social Security Number
Home Address
City
State
Zip
Phone Number
Full Name (including middle initial)
Title
Social Security Number
Home Address
City
State
Zip
Phone Number

Bank Reference

Bank Name
Account Number
Contact
Address
City
State
Zip
Phone Number

Trade Credit References (please list three (3) minimum - utility references not acceptable)

Company Name
Accounts Receivable Contact
Address
City
State
Zip
Phone Number
Company Name
Accounts Receivable Contact
Address
City
State
Zip
Phone Number
Company Name
Accounts Receivable Contact
Address
City
State
Zip
Phone Number

We hereby apply for credit and affirm financial responsibility, ability and willingness to pay invoices in accordance with published terms. Payment terms are net 30 days and begin from date of invoice. Invoices not paid within thirty (30) days may be charged against credit card listed above. The above information is warranted to be true and complete. We hereby authorize you to verify and collect information on us, including but not limited to bank references, trade credit references, consumer and/or commercial credit reports. We agree to pay all costs of collection and litigation on this account in accordance with the laws of the Creditor's State of Incorporation. If the buyer is a limited liability company or corporation, the undersigned agrees they will be personally and individually liable for any indebtedness owed by corporation or limited liability company. We agree that all decisions with respect to the extension or continuation of credit shall be in the sole discretion of the Creditor.
Authorized Signature: Date:
Printed Name: Title:
2126 Glenview Drive, Evansville, IN 47720 · Toll Free: 866.202.4491 · Phone: 812.437.3955 · Fax: 812.437.3971