Credit Application

APPLICATION FOR CREDIT

BY:

DUNS #:

NAME OF FIRM OR INDIVIDUAL:

STREET ADDRESS:

ADDRESS:

CITY:

STATE:

ZIP:

PHONE:

() - -

OWNERSHIP:

The following information must be provided. It will be held in the strictest confidence.

Corporation Check here if incorporated in the last 12 months Partnership Individual

PRIMARY FINANCIAL CONTACT:

PHONE:

()--

ACCOUNTS PAYABLE CONTACT:

PHONE:

()--

NUMBER OF YEARS IN BUSINESS:

NAME OF LARGEST CUSTOMER:

FINANCE:

BANK:

BANK ADDRESS:

BANK OFFICER OR DEPT:

PHONE:

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REFERENCES (OF LIKE INDUSTRIES):