- Print & Fax Credit Application
Fax Number (435) 655-8116
- Date:________________ Email:____________________
- Fax:_________________ Phone: ___________________
- Business Name:_________________________________
- Mailing Address:________________________________________________
- Shipping Address: _______________________________________________
- Business is: [ ] Sole Proprietorship [
] Partnership [ ] Corporation
- Business Began:______________________ Number
of Employees: ________
- *Resale Number: _________________________ Purchase will be resold:
______________
- FAXED confirmation of Purchase Order needed: [ ]
Yes [ ] No
- Name of person to contact regarding accounts payable: __________________
- Phone Number (if different than above) ____________________________
-
- THE OWNERS, OR IF CORPORATION, THE OFFICERS ARE:
-
- Name __________________________Title: ____________________
- Address: _______________________ City: ____________________
- State__________ Zip:___________ Phone: ___________________
- Name __________________________Title: ____________________
- Address: _______________________ City: ____________________
- State__________ Zip:___________ Phone: ___________________
Credit Reference (please give full name, address and telephone number)
- Name __________________________ City: _____________________
- Address: _______________________ Phone: ____________________
- State__________ Zip:___________ *Fax:
______________________
- Name __________________________ City: _____________________
- Address: _______________________ Phone: ____________________
- State__________ Zip:___________ *Fax:
_____________________
- Name __________________________ City: ______________________
- Address: _______________________ Phone: ____________________
- State__________ Zip:___________ *Fax:
_____________________
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