CREDIT APPLICATION
Date:  

Company Name:		      

Address:		          

City:		  
State:		  
Zip:		  

Number of Years in Business:
D and B Number:

Please list Proprietor / Partners / Corporate Officers:
Name Title Address Phone
 
  
 
 

 		      
 
 		      

Contact information for person(s) handling Purchase Orders & Invoice Payments:
Name Title Address Phone
 
  
 
 

 		      
 
 		      

Bank Information
Bank Name:    
Bank Address:    
City: State: Zip:
Bank Contact:
Title:
Phone:

Trade References (Must list 3 References):
Name Title Address Phone
 
  
 
 

 		      
 
 		      


The above information is herewith submitted for the purpose of opening an account and I do hereby certify this information to be true.
                                                  Signed:__________________________ Date:___________

American Dispatch Internal Use Only:          APP          DIS          RESloc:___________