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?

YesNo
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Please enter a valid phone number.
Business Email
example@example.com
What type of account are you applying for?

CODHouse Account
Primary Owner
Primary Owners Name

First NameLast Name
Owners Phone Number
Title of Primary Owner
Would you like to add another Owner?

YesNo
Second Owners Name

First NameLast Name
Second Owners Phone Number
Title of Second Owner
Trade References
Company Name
Contact Name

First NameLast Name
Phone Number
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
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?

YesNo
If so, describe
Is your company subject to any litigation?

YesNo
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:

I understand and acknowledge all statements on this application to be true.
Signature

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Business Credit Application Form

Company Information

Primary Owner

Trade References

Financial Information

Documents Upload