pchoice

 

 NAME/ADDRESS
 Last     First    MI   Title
 Name of Business   Tax ID Number
 Address  
 City State Zip Phone FAX

 COMPANY INFORMATION
 Type of Business
 Do you do Sales on the Internet?
 Legal Form Under Which Business Operates:         Corporation    Partnership     Proprietorship
 If Division/Subsidiary, Name of Parent Company:
 Owner Name:  Owner email:
 Branch Manager Name:  Branch Manager email:
 Purchasing Mgr Name:  Purchasing Mgr email:
 AP Name:  AP email:

 TRADE REFERENCES
 1. Company Name Contact Name
 Address  
 City  State Zip Phone FAX
 Date Opened    High Credit   Current Balance

 

 2. Company Name Contact Name

 Address  
 City  State Zip Phone FAX
 Date Opened    High Credit   Current Balance

 

 3. Company Name Contact Name

 Address  
 City  State Zip Phone FAX
 Date Opened    High Credit   Current Balance

 

 4. Company Name Contact Name

 Address  
 City  State Zip Phone FAX
 Date Opened    High Credit   Current Balance

 BANK REFERENCE
 Institution Name   Account Number  
 Address  
 City  State Zip Phone FAX

 STATEMENT OF ACCURACY AND PERMISSION TO VERIFY
 I hereby certify that the information contained in this credit application is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institution listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein.
 I agree with the terms above      Name      Date
 
 
 12318 Lower Azusa Road, Arcadia, CA 91006-5872 • Ph: 626-443-6433 • Fax: 626-443-1435

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