Customer Service
800.575.9618

CREDIT INFORMATION STATEMENT

Fill out and print the pdf form or submit your order online by completing the form below.

 

P.O. BOX 37025, TALLAHASSEE, FL 32315
(850) 575-9618 FAX: (850) 575-6508

Business Name:
Mailing Address: City/State/Zip:
Street Address: City/State/Zip:
Tel. No.: Fax No.:
Type of Business:
Person Responsible for Purchasing: Email:
 
This business is:  a Corporation a Co-partnership Limited Partnership a Proprietorship
We have been established: years under the above name. At present location since:
Does your company use purchase orders?  Yes No
Does your company have a valid resale certificate?  Yes No If "Yes", please attach copy of certificate.
 
The principle owners or officers are:
Name:
Position:
Address:
City:
Phone:
 
Our 3 major sources of supply with whom we have open accounts are:
Name:
Address:
City:
Phone:
Fax:
 
List all Bank References:
  (Bank) (Address) (Account No.) (Phone)
1.
2.
 
Have you ever filed bankruptcy?  Yes No * If "Yes", please state detail:
 
WE EXPECT OUR MONTHLY CREDIT REQUIREMENTS TO BE APPROXIMATELY: $
 
I/We understand that all information provided herein is correct and is for the purpose of obtaining credit and such information will be handled in confidence. Terms of payment are Net 30 days. Credit hold after 45 days. The undersigned has read and agrees to the payment terms and conditions of this firm.
 
Printed Name of Owner or Owner ONLY: