Date*:
Name*:
Address*:
Address2:
City*:
State*:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code*:
Phone*:
FAX:
Email
Type of Business*: ProprietorshipCorporationPartnership
Where Recorded*
Contractor's License*:
Sales Tax Number*
Company President*
Company Vice President
Company Treasurer
Name of Bank*
Bank City*

List 3 Local business suppliers with whom you have established credit
Local Business 1
 Name*:
 Address*:
 Address2:
 City*:
 State*:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
 Zip Code*:

Local Business 2
 Name*:
 Address*:
 Address2:
 City*:
 State*:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
 Zip Code*:

Local Business 3
 Name*:
 Address*:
 Address2:
 City*:
 State*:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
 Zip Code*:

ASSETS
Cash in Bank
Accounts Receivable Current
Accounts Payable Past Due
Inventory
Truck and Equipment
Furniture and Fixtures
Less Depreciation on Trucks, Equipment, Furniture & Fixtures
Miscellaneous
Land and Buildings
TOTAL ASSETS

LIABILITIES
Accounts Payable
Loans Payable
Officer Loans
Amount Owing on Truck or Equipment
Accrued Withholding Tax
Miscellaneous
Accrued Income Tax
Land and Buildings
Long Term Debt
Net Worth
TOTAL LIABILITIES

TERMS 2% 10th PROX (EXCEPT WHERE OTHERWISE INDICATED) NET 25th.
Officer Signature*:

For clarification of this application, call the credit office: 248 373-1070