325 Spring Lake Drive h Itasca, IL 60143 h Ph 708-345-8050 h Fax 708-345-8993
Credit Application and Agreement DATE:
/ /
Business/Name (the “Customer”): Street Address: P.O. Box: City: Zip: -
Year Established: Phone: ( ) Fax: ( ) State: Cell: ( ) -
Ownership Check which applies: Corp. Dunn & Bradstreet Rated?
Partnership No
LLC
Individual/Proprietorship
Tax Exempt
(attach copy of certificate)
Yes (D & B DUNN’S Number)
Requested credit limit: $ Federal Tax I.D. # Years in Business: Type of Business:
Account Manager: Years under current owners:
Officers/Partners/Owners: Name: Phone: ( ) Name: Phone: ( ) Name: Phone: ( ) Name: Phone: ( ) -
Title: Fax: ( Title: Fax: ( Title: Fax: ( Title: Fax: (
SS# Cell: ( SS# Cell: ( SS# Cell: ( SS# Cell: (
) ) ) ) -
- ) - ) - ) - )
-
Customer and any of its employees, representatives or agents are permitted to incur credit obligations with W.S. DARLEY & CO. (“DARLEY”), POLYBILT BODY COMPANY, LLC (“POLYBILT”) and ODIN FOAM or OHLER PUMP, each a division or DARLEY (“ODIN FOAM” and “OHLER”)(all together referred to as the “DARLEY COMPANIES”) and all terms of this Agreement may be enforced by any DARLEY COMPANY.
Bank Reference Bank Name: Account #: Phone: ( ) -
Address: Other Acct. #: Fax: ( ) -
Trade References Minimum of 3 open-accounts in industry required: Name: Phone: ( ) Contact Name: Name: Phone: ( ) Contact Name: Name: Phone: ( ) Contact Name:
Address: Fax: ( ) Account Number: Address: Fax: ( ) Account Number: Address: Fax: ( ) Account Number:
Credit Limit: $
Credit Limit: $
Credit Limit: $