Business Credit Application Form

Business Credit Application Form
Company Information
Name of Company
Full Legal Name
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the physical address the same as your billing/ mailing address?
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Email
example@example.com
What type of account are you applying for?
Primary Owner
Primary Owners Name

First NameLast Name
Owners Phone Number
Format: (000) 000-0000.
Title of Primary Owner
Would you like to add another Owner?
Second Owners Name

First NameLast Name
Second Owners Phone Number
Format: (000) 000-0000.
Title of Second Owner
Trade References
Company Name
Contact Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Account opened since

MonthDayYear
Date
Current Balance
Credit Limit
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Name 2
Contact Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Account opened since

MonthDayYear
Date
Credit Limit
Current Balance
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Financial Information
Number of Employees
Years in Business
Annual Net Income
Amount of Credit Requested
Tax I.D. Number
Have you or your officers or affilates ever filed a petition in bancruptcy?
If so, describe
Is your company subject to any litigation?
If so, describe
Documents Upload

*Required* Please included a copy of a business card or letterhead for the business
File Upload

Cancelof
Agreement and Authorization:

By signing below, I/We authorize Egan Wholesale Group to investigate all references and customary credit information sources regarding my/our credit and financial responsibility. I/We understand that this electronic signature has the same legal effect as a handwritten signature.
Authorized Employee

First NameLast Name
Employee Title
Date

MonthDayYear
Date
Please check the box below:
Signature
Should be Empty:

Business Credit Application Form

Company Information

Primary Owner

Trade References

Financial Information

Documents Upload