"*" indicates required fields Legal Company Name*DBA*Company Principal Responsible for Business Transitions*Title*Billing Address*Year Incorporated*City*State*Zip*Tel 1*Tel 2Fax*Website*Email* Fed ID(US)*Bus.ID (CAD)*Dunn & Bradstreet #*Office Contact*Email* A/P Contact*A/P Tel*A/P Email* Invoice Email* Bank Name & Address Bank Name*Bank Address*City*State*Tel*Account Number*Bank Contact* Trade References: Name & AddressName*Address*Contact*Tel 1*Email* NameAddressContactTel 1Email NameAddressContactTel 1Email Consent* I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for to verify the information contained herein.*Authorized Signature*Date* MM slash DD slash YYYY
