Application for Credit | Jodac Office Outfitters

Business / Organization Name *

Business Type *

Corporation
LLC
Partnership

Purchaser Name *

First

Last

Purchaser Email *

Phone *

Fax

Bill To Address *

Address Line 1

Address Line 2

City

State

Zip Code

Number of years at this address *

Same Ship To Address as Bill To *

Yes
No

Ship To Address *

Address Line 1

Address Line 2

City

State

Zip Code

Ownership Information *

Please list the Principals, Address, Phone Number

Financial Information *

Bank, Address, Phone, Bank Officer

ReferencesPlease list 3 business references below:

1 - Business Name *

1 - Name *

First

Last

1 - Email *

1 - Phone *

1 - Fax

1 - Address *

Address Line 1

Address Line 2

City

State

Zip Code

2 - Business Name *

2 - Name *

First

Last

2 - Email *

2 - Phone *

2 - Fax

2 - Address *

Address Line 1

Address Line 2

City

State

Zip Code

3 - Business Name *

3 - Name *

First

Last

3 - Email *

3 - Phone *

3 - Fax

3 - Address *

Address Line 1

Address Line 2

City

State

Zip Code

The undersigned hereby agrees that should a credit account be opened, and in the event of default in the payment of any amount due, and if such account is submitted to a collection authority, to pay an additional charge equal to the cost of collection including court costs.

Signature

Clear Signature