Trotta Tire Credit Application

Credit Application
Business Contact Info
Date

MonthDayYear
Date
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Resale Number*
E-mail*
Type of Business*
In Business Since*
Company Type*

Sole ProprietorshipPartnershipCorporationOther
Ownership Info
Officer/Principal Name*

First NameLast Name
Title
Social Security Number
Spouse Name*

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Accounts Payable Info
Accounts Payable Contact*

First NameLast Name
E-mail*
example@example.com
Banking Info
Bank Name*
Bank Account #*
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Phone Number*

Area CodePhone Number
Bank Contact Person

First NameLast Name
Trade References
Reference 1: Company Name*
Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail
Credit Limit
Current Balance
Reference 2: Company Name*
Contact Name

First NameLast Name
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number 2

Area CodePhone Number
Fax Number 2

Area CodePhone Number
E-mail
example@example.com
Credit Limit
Current Balance
Reference 3: Company Name*
Contact Name

First NameLast Name
Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number 3

Area CodePhone Number
Fax Number 3

Area CodePhone Number
E-mail
example@example.com
Credit Limit
Current Balance
Agreement

(By checking this box you are agreeing to our terms - should you have any questions please contact us)
Agreement and Terms*

By submitting this credit application, you authorize Trotta Tire & Rubber to make inquires into the banking and business references that you provided. I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. I hereby authorize the release of credit information requested by Trotta Tire & Rubber relevant to the above account.
Signature of Officer or Principal*

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Credit Application

Business Contact Info

Ownership Info

Accounts Payable Info

Banking Info

Trade References

Agreement