Credit Application for Business Account Form

Account Application Form
Lombardi's Sales Representative Name
Please include sales rep's name that helped you.
Corporate Name*
Trade Name*
Company Phone Number*
Company Fax Number
FEIN:*
Company Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company Type*

Sole ProprietorshipPartnershipCorporationLimited Liability CompanyOther

Corporate Officers, Partners, LLC Members, or an Individual Proprietor
Officer Name 1*

First NameLast Name
Officer Home Address 1*

Street Address

Street Address Line 2

CityState

Zip Code
Officer Phone Number 1*
Please enter a valid phone number.
Officer Social Security Number 1*
Form is fully encrypted end to end
Officer Driver License Upload 1*

Cancelof

Officer Name 2

First NameLast Name
Officer Home Address 2

Street Address

Street Address Line 2

CityState

Zip Code
Officer Phone Number 2
Please enter a valid phone number.
Officer Social Security Number 2
Form is fully encrypted end to end
Officer Driver License Upload 2

Cancelof
Business and Credit Info
Accounts Payable Contact*

First NameLast Name
Accounts Payable Phone*
Accounts Payable Fax
E-mail*
example@example.com
Preferred Method of Payment*

ACHCheckCredit Card (3% fee)
Bank Name*
Bank Address*

Street Address

Street Address Line 2

CityState

Zip Code
Bank Phone Number*

Business References
Reference 1: Company Name -(Preferably Food Distributors)*
Reference Address 1*

Street Address

Street Address Line 2

CityState

Zip Code
Reference Phone Number 1*
Fax Number
Reference E-mail 1
example@example.com
Type of Account
Reference 2: Company Name -(Preferably Food Distributors)*
Reference Address 2*

Street Address

Street Address Line 2

CityState

Zip Code
Reference Phone Number 2*
Fax Number 2
Reference E-mail 2
example@example.com
Type of Account 2
Reference 3: Company Name -(Preferably Food Distributors)
Reference Address 3

Street Address

Street Address Line 2

CityState

Zip Code
Reference Phone Number 3
Fax Number 3
Reference E-mail 3
example@example.com
Type of Account 3

Agreement

(By checking these boxes you are agreeing to our terms - should you have any questions please contact us)
Enter the word as it's shown*
Electronic Signature. By typing your name below, the undersigned agrees that their typed name is a valid electronic signature under applicable laws (e.g., E-SIGN, UETA) and binds them to this contract with the same effect as a handwritten signature.
Name*

First NameLast Name
Email*
example@example.com
Title*
Applicant agrees that he or she has the authority to sign on behalf of and bind Purchaser.
Should be Empty: