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Credit Application
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Bill To:
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Ship To:
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EXACT NAME:
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NAME:
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DIVISION or SUBSIDIARY:
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ADDRESS:
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ADDRESS:
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CITY: STATE:
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CITY: STATE:
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COUNTY: ZIP:
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COUNTY: ZIP:
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ATTENTION: |
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PHONE No:
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PHONE No:
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BUSINESS CREDIT REFERENCE
(PLEASE LIST A MINIMUM OF 3) |
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| NAME: | NAME: | NAME: |
| ADDRESS: | ADDRESS: | ADDRESS: |
| CITY: | CITY: | CITY: |
| STATE: ZIP: | STATE: ZIP: | STATE: ZIP: |
| PHONE No. ( ) | PHONE No. ( ) | PHONE No. ( ) |
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TYPE OF ACCOUNT
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TYPE OF ACCOUNT
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TYPE OF ACCOUNT
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| ( ) MERCHANDISE ( ) INSTALLMENT | ( ) MERCHANDISE ( ) INSTALLMENT | ( ) MERCHANDISE ( ) INSTALLMENT |
| ( ) OTHER_________________________ | ( ) OTHER_________________________ | ( ) OTHER_________________________ |
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GENERAL BUSINESS INFORMATION
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| TYPE OF BUSINESS: | ARE YOU SALES and/or USE TAX EXEMPT? | |
| D./B./A.___ Individual___ Partnership___ Corporation___ | ___YES - Insertyour certificate No. below | |
| Years In Business: Year of Inc.: | ___NO | |
| STATE OF INC.: | CERTIFICATE No.: | |
| OFFICER'S NAME(S): | TITLE | ACCOUNTS PAYABLE CONTACT |
| 1. | 1. | NAME: |
| 2. | 2. | PHONE No.: (____)______________EXT: |
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BANK REFERENCE
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| BANK NAME: ____________________________________OFFICER HANDLING: __________________________ |
| CITY:________________________STATE: ______ZIP: _____________ Phone No. (____)_____________________ |
| Checking Acct No.____________________Savings Acct. No.____________________ Other:___________________ |