Net Terms Application

Net Terms Application
Authorized Employee Information
Name

PrefixFirst NameLast Name
Title/Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Information
Name of Company Principal Responsible for Business Transactions
Type of Business
Tax I.D. Number
In Business Since :

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank References
Institution Name
Checking Account #
Contact Person

First NameLast Name
Contact Person Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Institution Name 2
Checking Account #
Contact Person

First NameLast Name
Contact Person Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trade References

Please consider alerting your trade references that you have listed them as a credit reference and request they respond as quickly as possible.This will allow us to process your application in the shortest time possible.
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
Company Total Assets
Annual Net İncome
Amount of Credit Requested
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
Company Name
Authorized Employee

PrefixFirst NameMiddle NameLast Name
Employee Title
Authorization and Certification

By signing below, you certify that the information provided above is true and correct to the best of your knowledge. You further authorize us to contact your
company’s bank and trade references and make credit report inquiries regarding your company’s credit limits and payment history, or other subjective measures of
your company’s credit worthiness:
Signature

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Net Terms Application

Authorized Employee Information

Company Information

Bank References

Trade References

Financial Information