*Company Name:



*Have Any Principles Ever Had a
Business Failure or Bankruptcy?

Owned Leased

*Bank Name:

*Bank Address:

*Account Type:

*Account Number:
*Bank Phone:


Please Read:

This information is submitted for the purpose of obtaining credit. The undersigned authorized you to make
such inquiries as are necessary to obtain credit information and authorizes my bank and/or suppliers to release information regarding my account(s). In consideration for the extension of credit, I/we agree to pay a late charge of 1.5% per month, a true annual rate of 18% per annum on
any amounts past due thirty(30)days
after billing, and to pay all responsible attorney's fees and the cost, if it becomes necessary to file suit to enforce collection.

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