Credit Application – Non-School District





Confidential Application For Credit

Name of person filling out this form
Legal Name of Firm
Doing Business As (DBA)
Street Address
City
State
County
Zip
Check one that applies
 Corporation Partnership Proprietorship Government LLC LLP Non Profit Other
In Business Since (Year)
Federal ID#
Type of Purchase Control
 PO Only Phone Contract
Taxable
 Yes No
If Yes, enter your County
If No, please attach your state's tax exemption certificate
A standard credit line of $2,000.00 will be assigned upon verification from references. If a greater credit line is requested please note below:
Credit Line Requested (Payment Terms Are Net 30)
Phone #
Fax#
Cell Phone #
E-mail Address

Bill To Information

Name on Invoice

P.O Box

Street

State/Zip

A/P Supervisor

Ship To Address (If Different)

Name on Invoice

P.O Box

Street

State/Zip

Purchasing Agent

Reference Information
Legal Name of Firm
Doing Business As (DBA)
D-U-N-S Number
Bank
Branch
Street Address
City, State, Zip
Phone #
Your Account #
Contact
Credit References
Company Name
Your Account No
Street Address
City, State, Zip
Phone #
Contact
Fax #
Company Name
Your Account No
Street Address
City, State, Zip
Phone #
Contact
Fax #
Company Name
Your Account No
Street Address
City, State, Zip
Phone #
Contact
Fax #
Company Name
Your Account No
Street Address
City, State, Zip
Phone #
Contact
Fax #