Credit Reference Form

We appreciate this opportunity to serve you. Our policy with new customers is to request three trade references and one bank reference. This information will be held in strict confidence.

Please complete this form to submit it to our Credit Department.

---

Customer Information: (* denotes required fields)

Organization *
Name *
Address *	Address 2
City *	State * Zip *
Phone # *	Email *

---

Bank Reference:

Bank *
Address *	Address 2
City *	State * Zip *
Account # *
Phone # *	Fax #

---

Trade Reference #1:

Name *
Address *	Address 2
City *	State * Zip *
Account # *
Phone # *	Fax #

---

Trade Reference #2:

Name *
Address *	Address 2
City *	State * Zip *
Account # *
Phone # *	Fax #

---

Trade Reference #3:

Name *
Address *	Address 2
City *	State * Zip *
Account # *
Phone # *	Fax #

---

Thank you for your cooperation.