Credit Application

Company Name

Legal Name

DBA

Billing Address

Shipping Address

Phone

Fax

Corp.

Partnership

Individual

Year Established

Type of Business

How Long in Business

Principals

Title

Has the firm or any of its Principals ever been bankrupt? Yes

If yes, please explain

Bank

Name		Account #
Address
Phone		Type of Account

Name		Account #
Address
Phone		Type of Account

Trade References

Name
Address
Phone		Fax

Name
Address
Phone		Fax

Name
Address
Phone		Fax

Name
Address
Phone		Fax

Are you listed with Dun & Bradstreet? Yes

Taxable Yes

Please note that we are required, by law, to charge Sales Tax on all sales unless we have a resale certificate on file in our office.

Accounts Payable Contact

Phone

The undersigned will/will not submit a financial statement. Any misrepresentation in this application will be considered evidence of a fraud, since this information is the basis for the granting of credit. As an inducement to grant credit, the undersigned warrants that the information submitted is true and correct. You are authorized to investigate the credit references listed.

Authorization signature to release bank information

Personal Guarantee of a Contract-Single Guarantor:

In consideration of signing the above contract with ROC Industries, I personally guarantee the performance of obligations of , in the above contract.

By
Address
City	State	Zip