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Please print this form and fax or mail when completed and signed. |
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| Firm
Name: _______________________________ Trade Style/DBA(s):
_________________________ Street Address: _______________________________________________________________________ P.O. Box: ____________________________________________________________________________ State/Zip: ________________________________ City: _______________________________________ Phone: Fax: |
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Type of Business (Circle One) |
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Sole Proprietorship LLC Partnership Non-Profit Corporation |
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State of Incorporation: Date of Incorporation: No. of Employees: |
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| Estimated Monthly Purchases: __________________ Credit Limit Requested: ____________________ Purchasing Agent: ____________________________ AP Contact: ______________________________ Federal Tax ID: Dun & Bradstreet #: |
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Company Officers |
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| Name:
____________________________________ Name: ____________________________________ Name: |
Title:
_____________________________________ |
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Bank References |
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| Name: __________________________________________ Phone: ______________________________ Address: _____________________________________________________________________________ City: _______________________________________ State/Zip: _________________________________ Contact Person: Account #: |
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Trade References |
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| Name: _________________________________________ Phone: ______________________________ Address: _____________________________________________________________________________ City: ______________________________________ State/Zip: _________________________________ Contact Person: __________________________________ Account #: ___________________________ Name:
_________________________________________ Phone:
______________________________ Name:
_________________________________________ Phone:
______________________________ |
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| 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: ________________________________ |
Date: ___________________________________ |
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Applying By Mail |
Applying By Fax |
| FJAproducts.com Attn: New Accounts PO Box 341 San Marcos, CA 92079 |
FJAproducts.com |