Coopersburg Kenworth - Coopersburg, PA - Coopersburg & Liberty Kenworth

Coopersburg Kenworth – Coopersburg, PA

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Your Name*

First Last

Your Email*

BUSINESS INFORMATION

Business Name

Tax ID*

Business Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Type of Business

Sole Proprietor

Partnership

Corporation

Business Phone*

Year Established

Nature of Business*

Tax Exempt

Yes

Tax Exempt Number

Please Attach Certificate

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Credit Limit Requested*

OWNER INFORMATION

If there are more than two owners/officers, please submit their information separately.

Name*

First Last

Title*

Phone*

Address (NO P.O. Box Addresses)*

Street Address City State / Province / Region ZIP / Postal Code Country

OWNER 2 (If Applicable)

Name

First Last

Title

Phone

Address (NO P.O. Box Addresses)

Street Address City State / Province / Region ZIP / Postal Code Country

BUSINESS REFERENCE INFORMATION

Please note, we require at least three references. If you’d like to provide additional references, please submit them separately.

Company Name 1*

Phone*

Fax

Email*

Account Number*

Current Balance*

Company Name 2*

Phone*

Fax

Email*

Account Number*

Current Balance*

Company Name 3*

Phone*

Fax

Email*

Account Number*

Current Balance*

The above information is for the purpose of obtaining credit and is warranted to be true. I/WE hereby authorize the firm to whom this application is submitted to investigate the references listed pertaining to MY/OUR credit and financial responsibility, and to obtain a credit report on all parties listed above. I acknowledge that entering/submitting my name below acts as a signature.

Applicant Signature/Title*

Date*

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