APPLICATOIN FOR CREDIT

Business Contact Information
Company Name*
Phone Number*
A/P Contact*
Phone Number*
E-mail
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date Business Commenced

MonthDayYear
Business Type
Business and Credit Information
Primary Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How Long at Current Address
Phone Number
Fax Number
E-mail
Bank Name
Bank Officer
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Phone Number
Bank Account Number
Tax Exempt
If Tax Exempt Please Attach a Tax Exemption Certificate

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Business / Trade References
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account Number
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account Number
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account Number
Company Name*
Agreement
1. All invoices are to be paid 30 days from the date of incoice.

2. Claims arising from invoices must be made within seven working days.

3. By submitting this application, you authorize Custom Controls Company to make inquiries into the banking and business/Trade reserences that you have provided
Representative Information
Name
Title
Date

MonthDayYear
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Business Contact Information