Print out this form, fill it out, and fax it to (586) 779-0876.
You may also mail it to us at 27941 Groesbeck Hwy., Roseville, MI 48066.

Company Information

Company Name:
Bill To Address:			Ship To Address:

Phone:

Fax:

Email:

Number of years in business:

D&B Number:

Principal Contacts

General Manager:
Purchasing Manager:
Controller:
Sales Manager:

Credit References

Company & Contact Name		Address	Phone
1.
2.
3.

Bank Name:		Account Number:
Address:		Officer:

Credit Line Requested:

Estimated Monthly Purchases:

The above information is provided for the purpose of extending credit to our company on your terms of net 30 days. To the best of our knowledge and belief, this information is accurate and may be relied upon in making your credit decision. We authorize our bank and suppliers to furnish you any information necessary to complete your evaluation of our credit history.

Name:

Title:

Date:

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