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Credit Application Form

Thank you for taking time to complete an application for credit.

Printable version

Our terms are Net 30. If no credit is established, our terms are C.O.D or Credit Card Only (American Express, MasterCard, Visa or Discover). All * fields are mandatory.

Date

Phone Number *

Company Name *

Fax *

Address *

Email *

City *

First Name *

State *

Last Name *

Zip *

Business structure *

Federal ID Number

Number of years in business

Dun & Bradstreet Number

Product line

Bank Reference

Bank Name

Account Number

Address

Officer

City

Fax Number

State

Zip

Trade References (please provide 3)

1. Name

Address

City

State

Zip

Fax Number

2. Name

Address

City

State

Zip

Fax Number

3. Name

Address

City

State

Zip

Fax Number

I hereby certify that the information in this credit application is correct. The information included in the credit application is for use by A-1 Servomotor Repair in determining the amount and conditions of credit to be extended. Further, I hereby authorize the bank and trade references listed in this credit application to release the information necessary to assist A-1 Servomotor Repair in establishing a line of credit for my company.

Submitted by *

Title *

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