Credit Application

Company Info

Company Name:
Contact:
Address:
City, St, Zip:
Phone:
Email:
Enter security code:
If you need to print this form please click here.
Fax:

Business Info

Business Type:
Tax Status:
Date Organized/Incorporated/
Ownership Acquired
Tax ID:

Officers/Partners/Owners:

(List two, unless Sole Proprietorship)
Name:
E-mail:
Title:
Address:
Phone:
Name:
E-mail:
Title:
Address:
Phone:

Payment Info:

Accounts Payable Contact:
Address:
City:
Contact:
Phone:

Trade References:

(Please do not include Visa or Mastercard)
Company Name:
Phone:
Fax:
Company Name:
Phone:
Fax:
Company Name:
Phone:
Fax:
You will be contacted by Accounts Receivable for the Accounts Payable Account Number.

Thank You!

We accept:

(Debit Cards must have the Visa or Master Card logo)

3125 Pine Tree Road, Suite B, Lansing, MI 48911
PH: 517.372.8360 / FX: 517.372.1504

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