Credit Application
You must have been in business with the same name and Federal ID Number for at least 3 years to apply for credit with Chameleon Services LLC.
How many years have you been in business under the same name and Federal ID Number?
(enter a number)
Business Legal Name:
*
(as it appears on license)
Business Trade Name:
*
(dba)
Business Street Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Your Billing Address Different From Your Street Address?
*
No
Yes
Business Billing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number:
*
Please enter a valid phone number.
Business Email:
*
example@example.com
Person Legally Responsible For Payments:
*
First Name
Last Name
Position Within Company
Federal ID Number:
*
Business Location:
*
Please Select
Storefront
Home
Office
Other
Please Explain:
*
Business Type:
*
Please Select
Corporation
Partnership
Sole Proprietorship
Number of Years in Business Under Current Name:
*
Contacts:
Primary Contact Name:
*
First Name
Last Name
Primary Contact Phone Number:
*
Please enter a valid phone number.
Primary Contact Email:
example@example.com
Secondary Contact Name:
*
First Name
Last Name
Secondary Contact Phone Number:
*
Please enter a valid phone number.
Secondary Contact Email:
example@example.com
Authorized Purchasers
Please list all persons authorized to make purchases within Chameleon.
Name:
First Name
Last Name
Title
Name:
First Name
Last Name
Title
Name:
First Name
Last Name
Title
Bank Information
Name of Bank #1:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Account Officer:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Name of Bank #2:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Account Officer:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Primary Trade References
Trade Reference #1:
Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Email:
example@example.com
Credit Line:
*
Trade Reference #2:
Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Email:
example@example.com
Credit Line:
*
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