Credit Reference Form

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Credit Reference Form
Date_______/_______/_______
Company____ ___________ ___________ ___________ ___________ ___________ _______ Contact Name & Title ________________________________________________
Physical Address (No PO Boxes) _______________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Phone_________________________________________ Fax_________________________________________ Email ___________________________________________
Years in business ____________ ____________ Number of employees ____________ ____________ Number of locations ____________________________
Business structure: ❍Private ❍Incorporated ❍Partnership
Federal ID Number __________________________________________________________ D&B Number __________________________________________________________
Credit Agencies
1. ____________ ____________ ____________ ____________ _| _ __________ ____________ ____________ ____________ ____________ ____________ ____________ ____________________
Agency Name
Address
Phone ____________ ____________ ____________ ____________ Fax ____________ ____________ ____________ ____________ Account Number _________________
Notes ________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
2. ____________ ____________ ____________ ____________ _| _ __________ ____________ ____________ ____________ ____________ ____________ ____________ ____________________
Agency Name
Address
Phone ____________ ____________ ____________ ____________ Fax ____________ ____________ ____________ ____________ Account Number _________________
Notes ________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Banks
1. ____________ ____________ ____________ ____________ _| _ __________ ____________ ____________ ____________ ____________ ____________ ____________ ____________________
Bank Name
Address
Phone ____________ ____________ ____________ ____________ Fax ____________ ____________ ____________ ____________ Account Number _________________
Notes ________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
2. ____________ ____________ ____________ ____________ _| _ __________ ____________ ____________ ____________ ____________ ____________ ____________ ____________________
Bank Name
Address
Phone ____________ ____________ ____________ ____________ Fax ____________ ____________ ____________ ____________ Account Number _________________
Notes ________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Trade References
1. ____________ ____________ ____________ ____________ _| _ __________ ____________ ____________ ____________ ____________ ____________ ____________ ____________________
Trade Group
Address
Phone ____________ ____________ ____________ ____________ Fax ____________ ____________ ____________ ____________ Account Number _________________
Notes ________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
2. ____________ ____________ ____________ ____________ _| _ __________ ____________ ____________ ____________ ____________ ____________ ____________ ____________________
Trade Group
Address
Phone ____________ ____________ ____________ ____________ Fax ____________ ____________ ____________ ____________ Account Number _________________
Notes ________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
By the signature below, authorization and permission is granted to contact the references listed above for the purpose of verifying
available credit information about the company named above.
____ ___________ ___________ ___________ ___________ _______ ____ ___________ ___________ _______ ___________ ___________ _______ ____ ___________ ___________ _______
Company Name
Authorized Signatory
Date
REV2 05-12
Office: 6565 N. Macarthur Blvd., Ste. 225
|
Irving, Texas 75039
Mail: 5621 S. Broadway, #320
|
Tyler, Texas 75703
p 214 624 5200
|
f 214 624 5101
|
e
|

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