Finance & Lease Information

Credit Application

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Company Name:
DBA (if different):
Contact Person:
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


 






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Dallas Sales Center
Danny McElroy
800-483-9971


The Nations Largest - White River Distributors, Inc.
lpg@aol.com
720 Ramsey - Batesville, Arkansas 72501
870-793-2374 | 800-548-7219 | FAX 870-793-8230