New Customers

corporation		partnership		sole proprietor

account number(s)
estimated amount of desired monthly credit

list at least 3 credit references
supplier name	address	phone

Referred by
The submitting purchaser consents to the release of any credit information required in approval of this account. The purchaser also agrees that the terms of payment are 30 days from the date of the invoice. Any past due accounts will be charged a 1-1/2% service charge per month.
Name of authorized person