11281 LEO LANE
DALLAS, TX 75229

(972) 243-5312
(800) 492-4428
FAX (972) 243-4632

Home | Bolts| Nuts | Screws | Washers | Manufactured Items | Email

Credit Application
Bill To:
Ship To:
EXACT NAME:
NAME:
DIVISION or SUBSIDIARY:
ADDRESS:
ADDRESS:
CITY:                                                      STATE:
CITY:                                                      STATE:
COUNTY:                                              ZIP:
COUNTY:                                              ZIP:
ATTENTION:
PHONE No:
PHONE No:

BUSINESS CREDIT REFERENCE
(PLEASE LIST A MINIMUM OF 3)
NAME: NAME: NAME:
ADDRESS: ADDRESS: ADDRESS:
CITY: CITY: CITY:
STATE:                      ZIP: STATE:                      ZIP: STATE:                      ZIP:
PHONE No. (          ) PHONE No. (          ) PHONE No. (          )
TYPE OF ACCOUNT
TYPE OF ACCOUNT
TYPE OF ACCOUNT
( ) MERCHANDISE ( ) INSTALLMENT ( ) MERCHANDISE ( ) INSTALLMENT ( ) MERCHANDISE ( ) INSTALLMENT
( ) OTHER_________________________ ( ) OTHER_________________________ ( ) OTHER_________________________

GENERAL BUSINESS INFORMATION
TYPE OF BUSINESS: ARE YOU SALES and/or USE TAX EXEMPT?
D./B./A.___ Individual___ Partnership___ Corporation___ ___YES - Insertyour certificate No. below
Years In Business:                           Year of Inc.: ___NO
STATE OF INC.: CERTIFICATE No.:
OFFICER'S NAME(S): TITLE ACCOUNTS PAYABLE CONTACT
1. 1. NAME:
2. 2. PHONE No.: (____)______________EXT:

BANK REFERENCE
BANK NAME: ____________________________________OFFICER HANDLING: __________________________
CITY:________________________STATE: ______ZIP: _____________ Phone No. (____)_____________________
Checking Acct No.____________________Savings Acct. No.____________________ Other:___________________