Net Terms Credit Application
Business Information
Business Name
*
DBA (if applicable)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Website
A/P Contact
*
A/P Contact Email
*
example@example.com
Owner Name
*
First Name
Last Name
Owner Email
*
example@example.com
Status
*
Please Select
S-Corporation
C-Corporation
Sole Proprietorship
Partnership
LLC
Bank
Name
*
Account #
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
D-U-N-S
*
EIN
*
State Resale Tax License
*
References
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Owner
*
Years Known
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Owner
*
Years Known
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Owner
*
Years Known
*
Signature
*
Date
-
Month
-
Day
Year
Date
I, the undersigned, am authorizing Bell ATM Services to contact our bank and trade references to obtain credit information for the purpose of extending credit to our company.
Submit
Submit
Should be Empty: