Credit App

Industrial Conveyor Corporation
5324 Crestview Drive
PHONE 901-382-2660 ext. 17 FAX 901-386-0082
Email: mark.beene@icc-industraline.com
http://www.icc-industraline.com

PLEASE FILL OUT THE FOLLOWING CREDIT APPLICATION, PRINT, AND FAX IT TO:

Industrial Conveyor Corporation @ 901-386-0082

APPLICATION FOR CREDIT

DATE:_______________________

ISSUED TO: Industrial Conveyor Corporation

FIRM NAME: (NAME OF FIRM REQUESTING STATEMENT)
___________________________________________________________________________________

MAILING ADDRESS: _____________________________________ PHONE:_____________________

CITY: __________________ STATE: ______________ ZIP CODE: _____________________________

FULL NAME OF OWNER OR OWNERS (OR AN AUTHORIZED OFFICER OF CORPORATION)
LIST HOME ADDRESS & ZIP CODE FOR PARTNERSHIP OR INDIVIDUAL.
1._________________________________________________________________________________

2._________________________________________________________________________________

PLEASE CHECK ONE:	INDIVIDUAL	PARTNERSHIP	CORPORATION	FED. TAX NO.

ADDITIONAL INFORMATION REQUIRED FOR CONDITIONAL SALES CONTRACTS UNDER THE UNIFORM COMMERCIAL CODE.

DEBTOR INDIVIDUAL SIGNING CONTRACT: ______________________________________________

TITLE:___________________________________

DEBTORS SOCIAL SECURITY NO: (FOR PARTNERSHIP OR INDIVIDUAL)_____________________

TYPE OF BUSINESS __________________________________

DATE STARTED_______________________

WE EXPECT OUR MONTHLY CREDIT REQUIREMENTS FROM YOU TO BE ABOUT $______________________

FORMER BUSINESS ________________________________ LOCATION ______________________

OWN OR RENT BUILDING - IF RENT, FROM WHOM?_______________________________________

REAL ESTATE MORTGAGE:____________________________________________________________

TRADE REFERENCES

NAME MAILING ADDRESS CITY STATE ZIP

1)___________________________________________________________________________________

2)___________________________________________________________________________________

3)___________________________________________________________________________________

NAME OF BANK:
CONTACT:
ACCOUNT NO:
MAILING ADDRESS:
CITY / STATE / ZIP

APPLICANTS SIGNATURE ATTESTS FINANCIAL RESPONSIBILITY, ABILITY AND WILLINGNESS TO PAY OUR INVOICES IN ACCORDANCE WITH FOLLOWING TERMS: NET 10

FIRM NAME:

BY:		TITLE: