MAIN Credit Application for Business Account Form

Business Contact Info
Application for Credit
MAIN Sales Representative
Company Name*
Phone Number*

Area Code Phone Number
Fax Number*

Area Code Phone Number
E-mail*
Company Address:*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Mailing Address (if different):

Street Address
Street Address Line 2
City State / 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 Name Last Name
Accounts Payable Phone*

Area Code Phone Number
Accounts Payable Fax

Area Code Phone Number
E-mail*
Company to Bill Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Bank Name*
Bank Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Bank Phone Number*

Area Code Phone Number
Checking:
Savings:

Credit References
Reference 1: Company Name
Address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
E-mail
Type of Account
Reference 2: Company Name
Address 2

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Phone Number 2

Area Code Phone Number
Fax Number 2

Area Code Phone Number
E-mail 2
example@example.com
Type of Account 2
Reference 3: Company Name
Address 3

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Phone Number 3

Area Code Phone Number
Fax Number 3

Area Code Phone Number
E-mail 3
example@example.com
Type of Account 3

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