Online Credit Application Credit Application # Date Customer Name Customer Number Billing Address Street Address City State / Province / Region ZIP / Postal Code Shipping Address Street Address City State / Province / Region ZIP / Postal Code Year Established: Corporation?YesNoTax Exempt #: D & B #: MCH Rated: Buying Group Affiliation: Member #: Bank Name Bank Address Street Address City State / Province / Region ZIP / Postal Code Bank Phone:Bank Fax: Account #: Contact Name: Trade References (complete mailing addresses)1. Name PhoneFax Address Street Address City State / Province / Region ZIP / Postal Code 2. Name PhoneFax Address Street Address City State / Province / Region ZIP / Postal Code 3. Name PhoneFax Address Street Address City State / Province / Region ZIP / Postal Code 4. Name PhoneFax Address Street Address City State / Province / Region ZIP / Postal Code Rep’s Name: Rep’s Evaluation of Applicant: Anticipated Monthly Sales: Δ
