Credit Application

Company Name:
DBA (if different):
Contact Person:
Email Address:
Street Address:
City:
State:
Zip Code:
Phone:
Federal Tax ID or SSN:
Type of business:
Date business established:
Amount of credit requested:
Are you a corporation?	Yes No
Name, title, and address of chief corporate officer #1:
Name, title, and address of chief corporate officer #2:
Name, title, and address of chief corporate officer #3:
Name and address of your resident agent:
Are you a partnership?	Yes No
Name and address of the partners:
Are you a sole proprietorship?	Yes No
Are you a sales tax exempt?	Yes No
Have you ever had credit with us before?	Yes No
Authorized purchasers:
Purchase order required?	Yes No

References

Give below the names or three persons not related to you whom you have known at least on year.
Name:
Address:
Phone:
Name:
Address:
Phone:
Name:
Address:
Phone:

Bank References

Give below the names or two banks.
Account # :
Contact person:
Name of bank:
Address:
Phone:
Account # :
Contact person:
Name of bank:
Address:
Phone:

I represent that the above information is true and is given to induce to extend credit to the applicant. My company and I authorize to make such credit investigation as sees fit, including contacting the above trade references and banks and obtaining reports. My company and I authorize all trade references, banks and credit reporting agencies to disclose to any and all information concerning the financial and credit history of my company and myself.

I Accept

Dallas Sales Center
Danny McElroy
800-483-9971

lpg@aol.com
720 Ramsey - Batesville, Arkansas 72501
870-793-2374 | 800-548-7219 | FAX 870-793-8230