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Credit Application

Please fill out this form completely and then click the submit button. Or click here for a printable PDF version of this form that you can submit via fax. * Required Fields
Customer Information
Name of Firm*	Phone* (with area code)
Address*	Fax (with area code)
City*	State*
Zip Code*	Email*

Company Information
Individual Partnership Corporation
Date of Inc.	State of Inc.

Applicable Corporate Officers, Partners or Owners (Signing Officers)
Name	Title
Name	Title
Name	Title
Accounts Payable Contact	Estimated Maximum Credit Required
Are Purchase Orders to be issued?	Yes	No

Bank Reference
Name	Contact Person
Account #	Phone
Address	Fax
City	State
Zip Code

Business References
Name	Contact Person
Account #	Phone
Address	Fax
City	State
Zip Code

Name	Contact Person
Account #	Phone
Address	Fax
City	State
Zip Code

Name	Contact Person
Account #	Phone
Address	Fax
City	State
Zip Code

The undersigned purchaser agrees to the following conditions: To pay all invoices within the terms of the contract, or invoice, whichever is applicable. To pay late payment charges at 1 1/2% per month on invoices that are greater than 30 days old. If suit is brought to collect any amount due, purchaser agrees to pay the cost of collection, plus reasonable attorney fees. At the option of the Company, the venue of any suit brought to collect this account may be held in Waukesha County, WI. Purchaser authorizes the Company to contact any of the references contained in this Credit Application for the purpose of establishing a line of credit. I certify that the above information is correct and is given for the purpose of obtaining credit and to reconfirm our existing accounts and balances with:
Company Name	Authorized Signature
Dated	Title

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