Online Credit Application Credit Application #DateCustomer NameCustomer NumberBilling 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 NameBank Address Street Address City State / Province / Region ZIP / Postal Code Bank Phone:Bank Fax:Account #:Contact Name:Trade References (complete mailing addresses)1. NamePhoneFaxAddress Street Address City State / Province / Region ZIP / Postal Code 2. NamePhoneFaxAddress Street Address City State / Province / Region ZIP / Postal Code 3. NamePhoneFaxAddress Street Address City State / Province / Region ZIP / Postal Code 4. NamePhoneFaxAddress Street Address City State / Province / Region ZIP / Postal Code Rep’s Name:Rep’s Evaluation of Applicant:Anticipated Monthly Sales: Δ
