Credit Application / Agreement Form
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1
2CREDIT APPLICATION / AGREEMENT
(Both sides must be completed in full to process)
Date __________________________
Salesperson ____________________________
Trade Name ____________________________________________________________________________________________
Billing Address ____________________________________________________
City _________________________________
State ________
Zip _____________
Phone (
) _______________________ Fax (
) __________________
Billing Email _________________________________________________
Contact ____________________________________
Company Type: (check one)
_____ Sole
_____ Partnership
_____ Corporation
____ LLC
How Long In Business _______________
Own Property
Yes or
No
Credit Requested $ _____________/Month
:
Federal Identification # _________________________________ State _________
Tax Exempt:
Yes or No
: (Circle one)
(If yes, attach state exemption form. By law a Reseller or Lawn Care Applicator only apply for exemptions)
Pesticide Applicator License # _______________________ Name __________________________ Expiration Date _________
(Include copy)
Bank Name __________________________________________
Acct # ___________________________________________
Address ____________________________________ City ________________________ State ________ Zip ____________
Bank Phone (
) __________________ Contact ____________________ Email _______________________________
Current Trade References:
**** IMPORTANT: TRADE REFERENCES WILL NOW BE OBTAINED VIA EMAIL.
PLEASE PROVIDE THE CORRECT EMAIL ADDRESS FOR THE APPROPRIATE CONTACT AT EACH COMPANY. ****
1) Name ______________________________________________
Email ___________________________________________
Contact __________________________
Fax (
) ______________________
Phone (
) ___________________
Address _______________________________________ City ___________________________ State ______ Zip __________
2) Name ______________________________________________
Email ___________________________________________
Contact __________________________
Fax (
) ______________________
Phone (
) ___________________
Address _______________________________________ City ___________________________ State ______ Zip __________
3) Name ______________________________________________
Email ___________________________________________
Contact __________________________
Fax (
) ______________________
Phone (
) ___________________
Address _______________________________________ City ___________________________ State ______ Zip __________
G:\WORKS\CREDITAPPLICATION.doc
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Parent category: Business