CREDIT APPLICATION

Company Information:
Company Name: ______________________________________________________Contact person: __________________________
Address: ____________________________________________________________________________________________________
City: ______________________________ State: _____________________________ Zip Code: _____________________________
Phone: ____________________________________ Fax: _______________________________ Email: ________________________
Type of business: ________________________________________ Year business opened: __________________________________
Federal ID# or SS# : __________________________________Principals name: ___________________________________________

Bank Reference:
Bank Name: ______________________________________________ Account #: _________________________________________
Address: ____________________________________________________________________________________________________
Contact Person: ___________________________Phone: ______________________ Date account opened: ____________________
Trade References:
Company Name: ______________________________________________________Contact person: __________________________
Address: ____________________________________________________________________________________________________
Phone: ____________________________________ Fax: _______________________________ Email: ________________________
Company Name: ______________________________________________________Contact person: __________________________
Address: ____________________________________________________________________________________________________
Phone: ____________________________________ Fax: _______________________________ Email: ________________________
Company Name: ______________________________________________________Contact person: __________________________
Address: ____________________________________________________________________________________________________
Phone: ____________________________________ Fax: _______________________________ Email: ________________________
The undersigned herby agrees that should a credit account be opened, and in the event of default in the payment of any amount due,
and if such account is submitted to a collection authority, to pay an additional charge equal to the cost of collection including court
costs. The undersigned individual who is either a principal of the credit applicant or a sole proprietorship of the credit applicant,
recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby
consents to and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from
time to time as may be needed, in the credit evaluation process.
Company: ________________________________________________________ Date: _____________________________________
Signature: ________________________________________________________ Title: _____________________________________
Please print your name: ________________________________________________________________________________________

1219 East Broadway Road Phoenix, Arizona 85040 Office: 602-276-7692 Fax 602-276-7766