Credit Application Form
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4Applicant Company Information:
OFFICE USE ONLY
Company Name (Legal)_________________________________________________
DATE______________________
D/B/A or Trade Name (if different than Legal)________________________________
APPV’D BY_________________
Billing Address________________________________________________________
CREDIT LIMIT $______________
SALESPERSON_____________
City________________________________ State____________ Zip Code_______
Classification: R G B Y
Phone (
)_________________________Fax (
)________________________
E-Mail______________________________________________________________
Purchase Order Required? (Circle One) YES NO Credit Limit Requested? $________
Circle One: Proprietorship
Corporation
Other (Specify)______________________
Date Established__________ State Incorporated_______ Federal ID #____________
Subsidiaries/Previous Business Name & Address______________________________
_____________________________________________________________________
Current Jobs:__________________________________________________________
Referred By:___________________________________________________________
Identify all Owners, Partners, or Officers:
Name
Title
Address
Phone
____________________________________________________________________ (
)________________
____________________________________________________________________ (
)________________
____________________________________________________________________ (
)________________
____________________________________________________________________ (
)________________
Identify Authorized Purchasers (REQUIRED)
Type of Business (Circle Primary Type)
1.________________________________
Asphalt/Paving
Flatwork
Renovation/Remodel
Steel/Rebar
2.________________________________
Bridge/Road
Home Builder
Government(non-profit)
Masonry
3.________________________________
Landscaping
HVAC/Plumbing
Excavating
Resale/Wholesale
4.________________________________
Mechanical
Gen. Contractor
Foundation
Roofing
Electrical
5.________________________________
Pre-cast Waterproofing
A/P Contact__________________________ Phone Number (
)_____________________ Fax (
)________________________
Purchasing Contact____________________ Phone Number (
)_____________________ Fax (
)________________________
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Parent category: Business