APPLICATION FOR CREDIT -

Application For Credit

Date :

Credit Limit Requested :

Company Legal Name :

Company Trade Name :

Telephone # :

Fax # :

E-mail Address : *

Years in Business :

State of Incorporation :

Purchase Order Required? ( ) Yes ( ) No

Type of Business :

Sales Rep :

Business Operates as:

Corporation
Partnership
Sole Proprietorship

Federal ID # :

Resale Certificate # :

(Must supply copy of certificate with application)

NAMES, TITLES, AND ADDRESSES OF OWNERS, PARTNERS AND/OR OFFICERS :

Name

Title

Address

Social Security #

Name (copy)

Title

Address

Social Security #

Name

Title (copy)

Address

Social Security #

Name

Title (copy) (copy)

Address

Social Security #

TRADE REFERENCES

Company

Name:

Address

Name:

Address

Name:

Address

Name:

Address

Contact Person

Phone

Fax

Phone

Fax

Phone

Fax

Phone

Fax

BANK REFERENCE

Bank

Name

Address

Contact

Phone

Phone Number

Phone

Fax

Checking Acc Number

A. CURRENT FINANCIAL STATEMENTS:

Attached
Will Mail Direct

(On credit requests greater than $20,000)

A. Person to Contact Regarding Accounts Payable:

Unconditional And Irrevocable Guaranty

The undersigned for and in consideration of your extending credit at my/our request to

hereinafter known as “Company” each personally guarantee to you payment at Surfaces by Pacific of any obligation of the Company and I/we hereby agree to bind myself/ourselves to pay you on demand any sum and all expenses of collection of the obligations and guaranty hereunder, including reasonable attorney’s fees, which may become due to you by the Company whenever the Company should fail to pay the same. I/we certify that all information provided is accurate and current. I/we agree to all terms and conditions of sale of Surfaces by Pacific. I/we also agree that all trade and bank references listed may release information to assist in the credit approval and collection process.

Signature without Title
Individually and as an authorized agent of the Company

Date

Print Name

Date of Birth

By (copy)

Signature without Title
Individually and as an authorized agent of the Company

Date (copy)

Print Name

Date of Birth

This form must be filled out completely to avoid delays in processing.