Credit Application

Companies, Universities, & Municipalities only!

Please fill out this form entirely. We will review your request and get back to you within 5 business days.

Bank Information

Bank Name:*

Bank Address:*

Contact Person for your account:*

Checking Account Number:*

Purshase Order # Required?*

Yes

Purchases Tax Exempt?*

Yes

Accounts Payable Contact*

Accounts Payable Phone Number:*

Federal ID EIN #:*

Sales Tax Exemp #:

Enter your Sales Tax Exempt #:
(if applicable)

Trade Reference 1:*

Enter Company Name, Contact, Address, Phone, Fax, & Account # for this trade reference

Trade Reference 2:*

Enter Company Name, Contact, Address, Phone, Fax, & Account # for this trade reference

Trade Reference 3:*

Enter Company Name, Contact, Address, Phone, Fax, & Account # for this trade reference

Agreement*

By checking the box below you agree to the following:

That you are authorized to release the information contained in this form.
I/We authorize the above listed references to release credit information concerning our account.
I/We agree to conform to the published terms of the Vendor and to pay all collection expenses incurred by the Vendor in collecting past due amounts.
You authorize us to contact your bank & trade references listed about your credit history.

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Additional Information:

Any additional information you feel we may need can be faxed to 812-925-7746
Please check the box below if you are sending Additional information

Yes

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