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Po Box 368 Maiden, NC 28650 Tel: 828-428-9094 Fax: 828-428-9970

Credit Application

Company Name: ____________________________________________ A/P Contact: ________________________________ Address: _______________________________________ City: ______________________ State: _______ Zip: ____________ Phone #: _____________________ Fax #: ___________________ Email: _________________ D & B #: _________________ Years in Business: ______ Year Started: _____ Form of Business: ___ Sole Proprietor ___ Partnership ____ LLC ___ LLP * Form of Business: ___ Sole Proprietor ___ Partnership ____ LLC ___ LLP *State of Incorporation ____________ Federal ID #: ____________________ Tax Exempt: ___ Yes ___ No (If yes attach exempt form) Annual Sales: ____________________________________ Number of Employees: ____________

Owners / Officers / Partners Name: _______________________________________ Title: _________________________ Email: _______________________ Name: _______________________________________ Title: _________________________ Email: _______________________ Name: _______________________________________ Title: _________________________ Email: _______________________

Bank References 1. Bank Name: ______________________________ Contact: ________________________ Contact Phone #: ______________ Address: _________________________________________________________________________________________________ Account #: ______________________ Contact Phone #: ______________________ Contact Fax #: ______________________ 2. Bank Name: ____________________________ Contact: ________________________ Contact Phone #: ________________ Address: _________________________________________________________________________________________________ Account #: ______________________ Contact Phone #: ______________________ Contact Fax #: ______________________

Trade References 1. Company Name: ___________________________Contact: ________________________ Contact Phone #: _____________ Address: _________________________________________________________________________________________________ Account #: ______________________ Contact Phone #: ______________________ Contact Fax #: ______________________ 2. Company Name: ____________________________Contact: ________________________ Contact Phone #: _____________ Address: _________________________________________________________________________________________________ Account #: ______________________ Contact Phone #: ______________________ Contact Fax #: ______________________ 3. Company Name: ____________________________Contact: ________________________ Contact Phone #: _____________ Address: _________________________________________________________________________________________________ Account #: ______________________ Contact Phone #: ______________________ Contact Fax #: ______________________

Authorization to Release Information Date: ___________ Firm Name: _________________ Address: __________________________________ Authorized By: ___________________________ Name: ____________________ Title: _______________ rev. 2/19/09 (tp)


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