Business Credit Application printable pdf download

Business Credit Application

11x17 Inc.

Mail to: P.O. Box 117

Ship to: 2034 North Jackson Street

11x17 Inc. Corporate office use

Jacksonville, Texas 75766

Phone:

(903) 541-0100

Date Received

References Check by:

Credit Report ran by:

Fax:

(903) 541-0040

Email:

Credit Approved/Denied by:

Credit Terms

Web:

Notes:

(Please fill in the entire form.)

Business Information:

Business Name

C-Corp

Cooperative

Corporation

Government

LLC

Municipality

Not for Profit

Partnership

S-Corp

Sole Proprietorship

Publicly Traded

Yes

Stock ID

Incorporated in the state of

Date of Incorporation

Subsidiary of

Main Contact

Federal ID / EIN

Main Phone

DUNS Num.

NAICS Code

Main Fax

SIC Code

Main Email

Physical Address

Bill to Address

Address Line 1

Address Line 2

City

State

Zip code

City

State

Zip code

Owner / Officers / Accounts Payable Contact

Name

Title

Phone

Bank Information

Bank Name

Bank Address

Phone

Account Number

Primary Contact

Trade Reference Information

Business Name

Contact

Phone

We hereby authorize the above listed credit references to release information to 11x17 Inc. for use in the evaluation of this request. On behalf of the applicant, the un-

dersigned hereby warrants that the above information be true, correct, and complete. All shipments are subject to the 11x17 Inc. terms and conditions, air bill, and rules

tariff on file at 11x17 Inc. offices and available to all applicants.

I hereby certify that I am authorized to sign and submit this application for and in behalf of the applicant

Signature

Date

NOTE: We suggest placing your first order by credit card while your account is being processed.

Please complete the above form and return via Email or Fax