New Account/Application For Credit

Customer Information

Name *
Address 1 *
Address 2
City/State/Zip *
CEO/President
Phone *
Fax *
Fed ID Number *
D&B Number
Type of Business
How Long in Business
Taxable? *	Yes No
(If not taxable in the state of Ohio, an Ohio tax form must be on file. A form will be faxed to you to fill out.)

Banking Information

Bank Name *
Address *
Contact Person *
Phone *

Trade/Supplier References

	SUPPLIER NAME	ADDRESS	PHONE #	CONTACT
1) *
2) *
3)
4)

* required fields

1) ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE.
2) ANY CREDIT GRANTED IS TO BE PAID WITHIN TERMS AND IN THE EVENT OF DEFAULT, CUSTOMER IS TO PAY REASONABLE COLLECTIONS CHARGES AND/OR ATTORNEY FEES.