CreditApplication-ChemUSA.doc

CREDIT APPLICATION For the purpose of establishing credit with CHEM USA Corporation, I, the undersigned, ______________________________ warrant the financial information below to be true to the best of my knowledge and hereby authorize any credit investigation needed for verification: Please check terms desired: Limit Desired: __________________ COD Company Check Postdated Check Legal Name: _____________________________ DBA: ___________________________ Billing Address: _____________________________ Ship To Address: _________________ City/State/Zip: _____________________________ ________________________________ Telephone: _____________________________ City/ State/Zip: ___________________ Fax: _____________________________ Tel/Fax: ________________________ Email: ________________________________________________________________ Business History Principle Owners/Officers: Name: _________________________________ Title: ___________________________ Date Established: ___________________ Business Type: # of Employees: ___________________ Corporation Annual Sales: ___________________ Partnership Tax ID #: ___________________ Proprietorship Dun Bradstreet # : ___________________ State Resale # : ___________________ Kind of Business: _________________ BANK REFERENCE Bank Name: ___________________ Checking Acct : __________________ Address: ___________________ Credit Line: __________________ Telephone: ___________________ Loan Acct #: __________________ Contact: ___________________ Saving Acct #: __________________ Please attach (1) A copy of the resale certificate (2) A void check copy TRADE REFERENCES 1. Company: ___________________________________ Contact: __________________ Address: ________________________________________________________________ Telephone: ___________________________________ Fax: _____________________ 2. Company: _____________