CREDIT REFERENCE REQUEST
Your company has been listed as a credit reference by a mutual customer. We appreciate your time in helping us complete this review. Please complete all sections of this form with accurate and current information. Your responses will be used solely to evaluate the customer's creditworthiness. Thank you for your quick reply.
Credit Reference Company
*
Request Date
*
-
Month
-
Day
Year
Date
Contact Name
*
Email
*
example@example.com
Business Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
CUSTOMER'S INFORMATION
Name of Business
Address 1
Address 2
City
State
Zip Code
CREDIT EXPERIENCE DETAILS
Length of Business Relationship
*
Your Terms
*
High Credit in Past 12 Months
*
Days Slow
*
Prompt Payee
*
Please Select
Yes
No
Discount Taken
*
Please Select
Yes
No
Balance Open on Account
*
Current Past Due
*
Remarks
Save
Submit Credit Reference
ContactID
CustomerNum
Should be Empty: