CREDIT APPLICATION

P.O. Box 27609; Los Angeles, CA 90027, Tel. 866-661-0211 Fax. 323-665-9062

TERMS NET 30

BUSINESS INFORMATION

NAME:

 

BUSINESS NAME:     DBA: 

 

STREET ADDRESS: CITY: STATE: ZIP:

 

PHONE:   FAX:   YEAR ESTABLISHED: TIME AT PRESENT LOCATION:

 

PARENT COMPANY:         PRESIDENT/OWNER:

 

BUSINESS TYPE:     STATE INCORPORATED IN:

 

NATURE OF BUSINESS:     FEDERAL TAX ID/SS#

 

TAX EXEMPT?     EVER FILED BANKRUPTCY?       FRANCHISE?

 

BILLING ADDRESS: CITY: STATE: ZIP:

 

ACCOUNTS PAYABLE CONTACT: PHONE:  FAX:

 

 

FINANCIAL INFORMATION

BANK NAME:   BRANCH:   ACCOUNT NUMBER:

 

TYPE OF ACCOUNT:   YEARS WITH INSTITUTION:    PRIMARY ACCOUNT HOLDER:

 

PURCHASE ORDER REQUIRED: IF YES, PLEASE INDICATE TYPE & FREQUENCY:

 

CERTIFICATE OF INSURANCE REQUIRED?

 

                       WORKERS COMPENSATION:     GENERAL LIABILITY:

 

 

 

REFERENCES (IF ANY)

REFERENCE 1

REFERENCE 2

REFERENCE 3
COMPANY NAME
CONTACT/TITLE
ADDRESS
CITY, STATE, ZIP
PHONE NUMBER
FAX NUMBER
       
       
LOCATIONS AUTHORIZED TO HAVE WORK PERFORMED
ADDRESS
ADDRESS
ADDRESS
ADDRESS
ADDRESS

 

I understand that the above information is given for the purpose of obtaining credit and I certify that, to the best of my knowledge, the above information is completed and accurate as of the date of this application. I hereby give permission to use tools necessary in determine credit worthiness. In the event of non-payment, I agree to pay all costs incurred for collections not limited to attorney fees and court costs.

 

AUTHORIZED DIGITAL SIGNATURE:      DATE:  

                                                  NAME:    TITLE:  

 

 

FOR HOLLYWOOD PLUMBING INC. USE ONLY
REFERENCES VERIFIED RCVD APPROVED/DENIED LETTER SENT ACCOUNT #