APPLICATION FOR CREDIT

COMPANY NAME:

PHONE:


ADDRESS:            

FAX NUMBER:

HEREBY APPLIES FOR CREDIT IN ACCORDANCE WITH THE TERMS AND CONDITIONS OF:

TO:

PumpRite, Inc.

124 N. York Rd., #242, Elmhurst, IL. 60126

ADAM KRZYZANOWSKI
SALES MGR
FAX #: (630) 578-1480
PHONE #: (630) 747-4628
CREDIT TERMS: NET 30 DAYS

THE FOLLOWING INFORMATION MUST BE PROVIDED. IT WILL BE HELD IN THE STRICTEST CONFIDENCE

 

 

CORPORATION

PARTNERSHIP

INDIVIDUAL

Ownership:

1

 

 

 

NAME(S) OF PRINCIPAL(S)

COMPLETE ADDRESS

PHONE NUMBER

 

2

Yes

 

 

 

NAME(S) OF PRINCIPAL(S)

COMPLETE ADDRESS

PHONE NUMBER

Finance:

 

 

 

BANK

BANK ADDRESS

 

 

 

 

 

 

BANK OFFICER OR DEPARTMENT

PHONE

 

1

 

 

 

BUSINESS NAME

PHONE

 

 

 

 

 

COMPLETE ADDRESS

FAX NUMBER

 

2

 

 

BUSINESS NAME

PHONE

 

 

 

 

COMPLETE ADDRESS

FAX NUMBER

 

3

 

 

BUSINESS NAME

PHONE

 

 

 

 

COMPLETE ADDRESS

FAX NUMBER

 

4

 

 

BUSINESS NAME

PHONE

 

 

 

 

COMPLETE ADDRESS

FAX NUMBER

 

 

CHECK HERE IF CASH SALES ARE OKAY UNTIL CREDIT IS APPROVED.

 

WE CERTIFY THAT ALL THE INFORMATION ON THIS FORM IS CORRECT. WE FULLY UNDERSTAND YOUR CREDIT TERMS AND AGREE TO THE PROPER PAYMENT IN CONSIDERATION OF EXTENDED CREDIT.

SIGNED: ______________________________________________________________________________

DATE: _____________________________ TITLE: __________________________________________

** IF TAX EXEMPT, PLEASE FAX CERTIFICATE WITH CREDIT APPLICATION