Please fill out the following form as completely as possible.  When finished, print, sign, and fax to (972) 937-1852 Att: Credit Department.
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Company details
Company Name
Company Type
Federal tax ID and/or Social Security number
Date business established
DBA (if applicable)

 

Are you a:

 

CORPORATION

State of incorporation
 

Names, titles, and contact numbers of your three chief corporate officers

Name and address of your resident agent:
 
PARTNERSHIP
Name and address of the partners:
Company Address (No PO Boxes please)
Address line 1
Address line 2
City
County
Zip Code
Country
Contact Name
Contact Email
Contact Tel
Contact Fax
Your web site address
   
Your bank account details
Bank Name
Bank account number
Contact name
Bank address
Bank (2) Name
Bank account number
Contact name
Bank address
Trade References  
Company name
Contact name
Company address and phone
Company name
Contact name
Company address and phone
Company name
Contact name
Company address and phone
Any other comments?
I represent that the above information is true and is given to induce  to extend credit to the applicant. My company and I authorize  to make such credit investigation as  sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to  any and all information concerning the financial and credit history of my company and myself. 
 
Authorized Signature

____________________________________________________________

Name
Title  
Date  
Please print, sign, and fax to (972) 937-1852

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