Customer Credit Application Business Name Shipping Address City: State: Zip: Telephone Fax: Mailing / Billing Address (if different) Website Address Type of Business (Organized as) Corporation Sole Proprietorship Partnership LLC Date Business Started Owner President: Vice President: Secretary / Treasurer: Accounts Payable Contact: Accounts Payable Telephone: Accounts Payable Fax: Accounts Payable Email Address: Name: Address: City: State: Zip: Telephone #: Fax#: Name: Address: City: State: Zip: Telephone #: Fax#: Name: Address: City: State: Zip: Telephone #: Fax#: Name: Address: City: State: Zip: Telephone #: Fax#: Account #: Authorized Signature Send ALL ABOVE INFORMATION WILL BE HELD IN STRICT CONFIDENCE AND USED FOR CREDIT PURPOSES ONLY
