Credit Application

(336)472-5000 Phone

(336)472-5225 Fax

Billing / Shipping Information

Official Company Name:
Bill to:		Ship to: (If Different)
E-mail Address:
Main Phone:
Main Fax:
A/P Fax:

Business Information

Nature of Business:	Corporation
	Partnership
	Proprietorship
	Subsidiary of:
	Division of:
Years in business:		Type of business:
D&B#
President/CEO:		Treasurer/Controller:
VP/Finance:		A/PManager:

Bank Information

Bank Name:		Contact Name:
Account No.		Phone:
Complete Address:

Trade References

Reference 1		Contact Name:
Phone No.		Fax No.
E-mail Address
Reference 2		Contact Name:
Phone No.		Fax No.
E-mail Address
Reference 3		Contact Name:
Phone No.		Fax No.
E-mail Address

CUSTOMER’S AUTHORIZATION TO RELEASE BANK AND TRADE INFORMATION Attention Bank and Trade References: Please provide information on all accounts listed as well as any loan information. You will be serving our interest best if you provide the information over the phone. Thank you. I/We hereby authorize you to whom this application is made, or your agents, to investigate my/our credit worthiness and will provide financial statements, tax returns etc., as you deem necessary.
Prepared by:			Date: (mm.dd.yy)
Title:

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