Credit Application | American Backflow

Business Name*(required)

Mailing Address*

City/State/Zip*

Street Address

City/State/Zip

Tel. No.*

Fax No.

Person Responsible for Purchasing

This business is a

We have been established below years under the above name

At present location since

Does your company use purchase orders?

Does your company have a valid resale certificate?
YesNo

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)

(Bank)

(Address)

(Account No.)

(Phone)

Have you ever filed bankruptcy?

YesNo

* 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.*
Yes

Printed Name of Owner or Officer ONLY