Credit Application | Falson Supply Co., Inc.

Credit Application

Falson Supply Company Applicaton For Credit Form

* Name of firm or individual:

Years incorporated:

* Type of business:

* Address:

Years at this address:

* City

	* State:	* Zip:

* Phone:

* Fax:

* Email:

The following information must be provided. It will be held in the strictest confidence.

Corporation	Check here if incorporated in past 12 months
Partnership	Individual

Ownership:

1. Name(s) of principal(s) Title:

2. Name(s) of principal(s) Title:

3. Name(s) of principal(s) Title:

Finance:

Bank Name:
Bank Address:
Contact:

Account Number:

Phone:

Fax:

References:

1. Business Name: Phone: Fax:

2. Business Name: Phone: Fax:

3. Business Name: Phone: Fax:

We certify that all information on this form is correct, and that falson supply co. has our approval to contact the above mentioned companies and financial institutions for credit and banking references.

Date:

(Example.. 01/01/09)

Signed:

Title:

TERMS: NET 30 DAYS - BALANCES BEAR A MONTHLY PERIODIC
RATE OF 1.5% BEING AN ANNUAL PERCENTAGE OF 18%
* RESALE CUSTOMERS MUST FURNISH A BLANKET RESALE CERTIFICATE *

* Denotes a required field.