Commercial Credit Application - State Of Indiana
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1
2COMMERCIAL CREDIT APPLICATION
RETURN TO:
Premier Ag Co-op, Inc.
DBA:
Premier Companies
Premier Energy
Heyob Energy
Branch _____________________________________________________
P.O. Box 1947 • Columbus, IN 47202
812-379-9501 • Fax 812-372-6801
1.
FIRM NAME _____________________________________________
Line of Credit Desired
$______________________________
Additional Trade Name ______________________________________
Line of Credit Approved
$______________________________
________________________________________________________
Business Phone (________) ______________________________
❑
Address __________________________________________________
Taxable
Social Security No. ____________________
❑
City _______________________ State __________ Zip ___________
Non Taxable
Employer I.D. No. ____________________
Billing Address ____________________________________________
Retail Sales Tax Exemption
City _______________________ State __________ Zip ___________
Certified _____________
(please attach sales tax exemption certificate)
Nature of Business __________________________________________________________________________________________________
❑
❑
❑
❑
❑
Corporation
Partnership
Proprietorship
LLC
Other
Date Business Established ______________
If incorporated, State in which incorporated ______________________ Year ___________
Person to contact regarding financial matters:
Name ___________________________________ Title _____________________________
Address ________________________________________________________________________ Phone No. (______) ________________
2.
NAMES OF OWNERS, PARTNERS or OFFICERS:
a. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
b. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
c. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
3.
BANK REFERENCES: Bank Name_____________________________________________ Branch _________________________________
Address ______________________________________________________________________________________________________________
Loan Officer _________________________________________________________________ Phone __________________________________
❑
❑
❑
❑
Bank Credit Line _________________________________
Secured?
Yes
No
Personal Guaranty
Yes
No
Explain: ______________________________________________________________________________________________________________
❑
❑
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Checking Acct. No. ___________________
Savings Acct. No. ___________________
Loan Acct. No. ______________________
4.
TRADE REFERENCES:
a. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
❑
❑
Secured?
Yes
No Explain: ________________________________________________________________________________
b. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
❑
❑
Secured?
Yes
No Explain: ________________________________________________________________________________
SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS
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