Online Credit Application

All items with a * are required.

COMPANY INFORMATION
*Company Name:
*Name of Owner:
BILLING ADDRESS
*Street Address:
*City:
*State:
*Zip:
*Phone:
Fax:
*Accounts Payable Contact:
SHIPPING ADDRESS
*Street Address:
*City:
*State:
*Zip:
*Phone:
Fax:
CREDIT INFORMATION
*Monthly Credit Request:
*Type of Business:
*Years in Business:
*Purchase Order Required: Yes No
BANK REFERENCES
*Bank Name :
*Name of Bank Officer:
*Title of Bank Officer:
*Street Address :
*City:
*State:
*Zip:
*Loan Account Number:
*Checking Account Number:
TRADE REFERENCES (excluding credit cards)
*Company Name:
*Address:
*City:
*State:
*Zip:
*Phone:
Fax:
*Contact Name:
TRADE REFERENCE#2
*Company Name:
*Address:
*City:
*State:
*Zip:
*Phone:
Fax:
*Contact Name:
TRADE REFERENCE#3
*Company Name:
*Address:
*City:
*State:
*Zip:
*Phone:
Fax:
*Contact Name:

 

By submitting this form, I authorize Gholkar's Incorporated to contact the references I have listed above. I permit Gholkar's Incorporated to inquire about my past credit history with these references. I understand that the information obtained will be used to determine my creditworthiness.

My Name here constitutes understanding of and agreement with the terms of this application.
(enter your name):

 
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