Firm Name: ________________________Contact person: _______________________
Address: _______________________________________________________________
City: ________________________State: _________________Zip: ________________
Type of business: ___________________ Year business opened: __________________
Phone: _________________ Fax: ___________________ Email: __________________
Federal ID# or SS# : _____________________ Principals name: ___________________
Name: ________________________________ Account #: _______________________
Address: _______________________________________________________________
City: _____________________ State: __________________ Zip: __________________
Phone: ________________________ Date account opened: ______________________
Firm name: ____________________________ Phone: ___________________________
Firm name: ____________________________ Phone: ___________________________
Firm name: ____________________________ Phone: ___________________________
The undersigned herby agrees that should a credit account be
opened, and in the event of default in the payment of any amount due, and if
such account is submitted to a collection authority, to pay an additional charge
equal to the cost of collection including court costs.
The undersigned individual who is either a principal of the credit
applicant or a sole proprietorship of the credit applicant, recognizing
that his or her individual credit history may be a factor in the
evaluation of the credit history of the applicant, hereby consents to and
authorizes the use of a consumer credit report on the undersigned by the
above named business credit grantor, from time to time as may be needed,
in the credit evaluation process.
Company: ______________________________ Date: _____________________
Signature: ______________________________ Title: ______________________
Please print your name: _______________________________________________