Credit Application

Personal Information

First Name
Middle Initial
Last Name
Business Name
Tax I.D. Number
Address
City
State
Zip
Phone
E-Mail

Company Information

Type of Business
In Business Since (yyyy-mm-dd)
Legal Form Under Which Business Operates

If Division/Subsidiary, Name of Parent Company
In Business Since (yyyy-mm-dd)
Name of Company Principal Responsible for Business Transactions
Principal Title
Address
City
State
Zip
Phone

Bank References

Checking Account

Institution Name
Checking Account #
Address
Phone

Savings Account

Institution Name
Savings Account #
Address
Phone

Business Equity Loan

Institution Name
Business Equity Loan #
Address
Phone
Loan Balance

Trade References

#1

Company Name
Contact Name
Address
Phone
Account Open Since (yyyy-mm-dd)
Credit Limit
Current Balance

#2

Company Name
Contact Name
Address
Phone
Account Open Since (yyyy-mm-dd)
Credit Limit
Current Balance

#3

Company Name
Contact Name
Address
Phone
Account Open Since (yyyy-mm-dd)
Credit Limit
Current Balance

Verify Information

By checking this box, I hereby certify that the information contained herein 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 institutions 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.