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Please print this form and fax or mail when completed and signed.

 Firm Name: _______________________________  Trade Style/DBA(s): _________________________

 Street Address: _______________________________________________________________________

 P.O. Box: ____________________________________________________________________________

 State/Zip: ________________________________ City: _______________________________________  

 Phone:                                                              Fax: 

Type of Business (Circle One)

Sole Proprietorship        LLC       Partnership        Non-Profit        Corporation

 State of Incorporation:                  Date of Incorporation:                       No. of Employees: 

 
 Estimated Monthly Purchases: __________________  Credit Limit Requested: ____________________

 Purchasing Agent: ____________________________  AP Contact: ______________________________

 Federal Tax ID:                                                         Dun & Bradstreet #:

Company Officers

 Name: ____________________________________

 Name: ____________________________________

 Name: 

 Title: _____________________________________

 Title: _____________________________________

 Title: 

Bank References

 
 Name: __________________________________________  Phone: ______________________________

 Address: _____________________________________________________________________________

 City: _______________________________________ State/Zip: _________________________________

 Contact Person:                                                              Account #:

Trade References

 
 Name: _________________________________________  Phone: ______________________________

 Address: _____________________________________________________________________________

 City: ______________________________________ State/Zip: _________________________________

 Contact Person: __________________________________ Account #: ___________________________

 Name: _________________________________________  Phone: ______________________________

 Address: _____________________________________________________________________________

 City: ______________________________________ State/Zip: _________________________________

 Contact Person: __________________________________ Account #: ___________________________

 Name: _________________________________________  Phone: ______________________________

 Address: _____________________________________________________________________________

 City: ______________________________________ State/Zip: _________________________________

 Contact Person: __________________________________ Account #: ___________________________

This is my authorization to FJAproducts.com to contact the references provided so that information may be obtained to consider granting the extension of credit on open account terms, which will be determined by FJAproducts.com.  My signature below signifies my approval for the listed references to respond to credit inquiries from FJAproducts.com.  A late charge of 1.5% can be assigned on accounts paid beyond our terms.
 
 Name: ___________________________________

 Signature: ________________________________

 
 Title: ____________________________________

 Date: ___________________________________

Applying By Mail

Applying By Fax

 FJAproducts.com
 Attn: New Accounts
 PO Box 341
 San Marcos, CA 92079

 FJAproducts.com
 Attn: New Accounts
 (760) 761-0976