Business Name: _________________________________ 
Address: _______________________________________
 ______________________________________________
City: _______________________  State: _____________
Zip Code: ______________ Tel. No. _________________
Owner/Manager _________________________________

How long in business ____________ D & B Rated ______
 
Trade References: 
1.) Name: ______________________________________ 
Address: _______________________________________
 ______________________________________________
City: _______________________  State: _____________
Zip Code: ______________ Tel. No. _________________

2.) Name: ______________________________________ 
Address: _______________________________________
 ______________________________________________
City: _______________________  State: _____________
Zip Code: ______________ Tel. No. _________________

3.) Name: ______________________________________ 
Address: _______________________________________
 ______________________________________________
City: _______________________  State: _____________
Zip Code: ______________ Tel. No. _________________

4.) Name: ______________________________________ 
Address: _______________________________________
 ______________________________________________
City: _______________________  State: _____________
Zip Code: ______________ Tel. No. _________________


Bank References: 
1.) Name: ______________________________________ 
Address: _______________________________________
 ______________________________________________
City: _______________________  State: _____________
Zip Code: ______________ Tel. No. _________________

2.) Name: ______________________________________ 
Address: _______________________________________
 ______________________________________________
City: _______________________  State: _____________
Zip Code: ______________ Tel. No. _________________

Credit line requested $_____________________________ 

Pending lawsuits against Company: __________________ 

The undersigned authorizes inquiry as to credit information. 
We further acknowledge that credit privileges, if granted, 
may be withdrawn at any time. 


______________________________
  [clearly print name after signature]

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