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Credit Application (copy) (copy)

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Credit Application

Teammate Name *

Widget

Custom widget — review for native equivalent.

Franchise *

Spreadsheet to Form

Custom widget — review for native equivalent.

Simple LLC

LLC

General Manager Email

example@example.com

Area Director Email

example@example.com

Vice President Email

example@example.com

CSA Email

example@example.com

CSA 2 Email

example@example.com

This credit application must be filled out in full and signed by a Corporate Officer/Owner. The information required in Sections B, C and D can be provided on a separate document given both this credit application and the additional documentation is signed by a Corporate Officer/Owner.

A. Company Information

Legal Name of Company/Association

Address

Phone

Type of Business

Number of Years Operating

Division/Subsidiary of

EIN #

Duns and Bradstreet #

Legal Name of Holding Company or Association

Date of Incorporation

Full Name of Owner/Partner/CEO

Title

Full Name of Financial Controller

Title

Full Name of Person Authorized to Execute this Application

B. Accounting Contact

Name

Title

Contact Email

example@example.com

Phone

Fax Number

C. Banking Information

Name

Address/Branch

Account #

Contact Email

example@example.com

Phone

Fax Number

D. Trade References (non-utility)

Name of Business

Address

Contact

Phone Number

Fax Number

Name of Business

Address

Contact

Phone Number

Fax Number

Name of Business

Address

Contact

Phone Number

Fax Number

E. Additional Billing Requirements

Signature of Corporate Officer/Owner

Title

Date

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