CREDIT APPLICATION - Fax Version

Please complete the following. All information will be held in the strictest of confidence.

Company Name:________________________________________________________________

Address:______________________________________________________________________

_______________________________________________________________________

Owner's Name: __________________________ Phone #: ______________________________

Owner's Home Address: ___________________

Drivers Lic. #_________________________ ___________________

COMPANY INFORMATION: __ Sole-Proprietorship __ Corporation __Partnership

CREDIT REFERENCES:

1._______________________________________________ Telephone:______________

2._______________________________________________ Telephone:_______________

3._______________________________________________ Telephone:_______________

BANK INFORMATION:

Name of Bank:___________________________________________________________

Address: _______________________________________________________________

Account No.:______________________________

Phone: _______________________