Credit Application

Company Information
Company Name
DBA (if applicable)
Phone
Fax
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Accounts Payable Contact
Accounts Payable Email

Please provide the email address best suited for receipt and payment of invoices
Year Business Established
Federal EIN
D&B No.
Sales Tax Exempt No.
Owner Name
Requested Credit Limit
Bank Information
Bank Name
Checking Account Number
Bank Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Contact Name
Bank Contact Phone
Bank Contact Fax
Trade References Information
Company Name 1
Contact Name 1
Phone 1
Email 1
Company Name 2
Contact Name 2
Phone 2
Email 2
Company Name 3
Company Name 3
Phone 3
Email 3
Purchaser Contact Information
Purchaser Contact
Purchaser Title
Purchaser Phone
Purchaser Email
Consent*
We certify that all the information on this form is correct. We fully understand your credit terms and agree to the prompt and timely payment of all amounts due in consideration of your extending credit to us. We understand and agree that a late payment charge can be added to any past due amounts. By submitting this application, we authorize Blue1 DEF Solutions, to make inquiries into the banking and business/trade references we have supplied.
Signature
Title
Date
MM slash DD slash YYYY

Company Information