Application for Credit

Payment Data

Principal Owners - Stockholders - Partners - Officers of Company (1 required)

Bank References

Notice: The Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has, in good faith, exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with the law concerning this credit is the Federal Trade Commission, Division of Credit Practices, 6th and Pennsylvania Avenue, NW, Washington, DC 20580.

To the best of my knowledge the above statements are true. By submitting the following information A) indicates my permission to obtain credit information from the sources referenced and B) Attests financial responsibility and willingness to pay invoices in accordance with terms.

Credit Terms are 25 days unless otherwise specified in a written contract

* All items with an asterisk are required