MAIN Credit Application for Business Account Form

Business Contact Info

Application for Credit
MAIN Sales Representative
Company Name*
Phone Number*

Area CodePhone Number
Fax Number*

Area CodePhone Number
E-mail*
Company Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Type*

IndividualSole ProprietorshipLLCCorporationOther
Type of Business:*
No. of years in business: *
Principals of Ownership: *
Officers of the Company: *
Persons authorized to sign for Company: *

Business and Credit Info
Accounts Payable Contact*

First NameLast Name
Accounts Payable Phone*

Area CodePhone Number
Accounts Payable Fax

Area CodePhone Number
E-mail*
Company to Bill Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Name*
Bank Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Phone Number*

Area CodePhone Number
Checking:
Savings:

Credit References
Reference 1: Company 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
Type of Account
Reference 2: Company 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 2
example@example.com
Type of Account 2
Reference 3: Company 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 3
example@example.com
Type of Account 3