Please complete the following credit application to help us assess your eligibility for business credit. This information will remain confidential and will only be used for evaluation purposes.

Business Information

Business Name:

Tax ID Number:

Address:

City, State, ZIP:

Phone:

Type of Business (Corporation, Partnership, Proprietorship):

Years in Business:

Bank References

Bank Name:

Account Number:

Contact Name:

Phone:

Trade References

Company Name:

Contact Name:

Phone:

Address:

Credit Request

Requested Credit Limit:

Terms Requested:

Certification

I hereby certify that the information provided is complete and accurate. I authorize the release of information to verify creditworthiness.

Authorized Signature:

Date:

How Collection Agency Works

Business Credit Application

Business Information

Bank References

Trade References

Credit Request

Certification