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Credit Application

Thank you for your interest in our company. Please fill out the form below and someone from our credit department will contact you on the status of your application.

Company Name:*

Address:*

Phone:*

Fax Number*

Email:

City:*

State:*

Zip Code:*

Business Owner (s)

Individual: Partnership: Corporation: Other:

Person Responsible for payment*

Federal ID or Social Security:*

Business and Credit Information

Billing Address:*

City:*

State:*

Zip Code:*

Phone:*

Fax Number:*

Email:*

Bank Name:*

Bank Address:*

Bank Phone:*

Bank State:*

Bank Zipe Code*

Type of Account:

Checking: Savings: Other:

Business References:

Please list (3) references which include Company Name Address City State Phone Fax Email Type of account

References:*

Agreement

1. All invoices are to be paid 10 days from the date of statement. If payment in full is not received within 30 days of statement date, a finance charge of 1 1/2 % per month shall be imposed upon the unpaid balance of your account for the previous month and credit privileges will be terminated. 2. Claim arising from invoices must be made within seven working days. 3. By submitting this application, you authorize EJE or EJE'S commissioed ajent to make inquires into the back and business/trade references that you have supplied