15 W. 650 South Frontage Road, Burr Ridge, IL 60527 Phone - 708-447-4500 • Fax - 708-447-7796
Can Also Apply Online www.lafasteners.com
Application for Open Account Date Name of Account
Phone
Fax
Billing Address
City
State
Zip
Shipping Address
City
State
Zip
Bank Reference
Phone
City
State
Zip
Name
Phone
Fax
Address
City
State
Name
Phone
Fax
Address
City
State
Name
Phone
Fax
Address
City
State
Account Number Address
Trade References
Purchasing Information
Zip
Zip
Zip
Principal Persons
Purchaser’s Resale #
President
Purchaser’s ICC #
Vice President
Anticipated Monthly Requirements
Purchasing Agent Type of Business
L.A. Sales Representative 155