Business Name _ Date _
Address _
City _ State _ Zip _
Owner/Manager _ Tel.No. _
How long in business _ D & B Rated _
Trade References:
Name _ Address _
Name _ Address _
Name _ Address _
Name _ Address _
Bank References:
Name _ Address _
Name _ Address _
Credit line requested $_
Pending lawsuits against Company:

_

The undersigned authorizes inquiry as to credit
information. We further acknowledge that credit privileges, if
granted, may be withdrawn at any time.

_________________________________

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