2715 Norton Creek Drive West Chicago, Illinois 60185 PHONE 630-443-2200 FAX 630-443-2300 (CREDIT DEPT) CONFIDENTIAL CREDIT APPLICATION AND AGREEMENT (Fill Out Completely)
Business Hours of Operation:
a.m. to p.m. Federal ID #:
Company Name:
Duns #:
Shipping Address:
City:
State:
Zip:
Telephone: Fax:
Accounts Payable Contact/E-mail address:
Billing Name:
Billing Phone:
Billing Address:
Type of Business:
Date Established:
Type of Entity:
Sole Proprietor Partnership Corporation (state) Other
Key Management Members and Owners
Title
Ownership %
Bank:
Address:
State: Zip:
Phone:
Contact: Acct#:
Three Trade References (two of which must be carriers), Addresses, and Phone Numbers:
The above information is provided for the purpose of extending credit to our company on your terms. The undersigned certifies that all the information on this form is true, and understands that payment of all charges is due within (30) days from invoice date.. The undersigned understands and agrees if payment terms are not met, this will result in forfeiture ofany discounts or price reductions. To the best of our knowledge and belief, the information is accurate and true. We authorize our bank and suppliers to furnish you any information necessary to complete your evaluation of our credit history.
SIGNATURE(Initials): DATE:
Type or print name: