Commercial Form

Submitted by:
Company/Person’s Name (Check One)

Address
City, State, Zip , ,
Years at this Address

Telephone H:
W:
Date Incorporated
E-mail :
Ownership:
Owner(s) Corporate Officers
#1.
#2.

Home Address
City, State, Zip , ,

Home Phone Number:
Driver’s License Number:
State Issued:
Tax Status:
Prime Contact for Credit and Collections
Three References: (Open Charge Accounts Only – No Credit Cards)
Name
#1.
#2.
#3.

#1 Address
City, State, Zip , ,
Phone:
Account #:
Bank Reference:

#2 Address
City, State, Zip , ,
Phone:
Account #:
Bank Reference:

#3 Address
City, State, Zip , ,
Phone:
Account #:
Bank Reference:

I/We agree to pay full cost of service charges, collection fees, and attorney fees, if net 30 day credit terms are exceeded.

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