| APPLICATION FOR CREDIT |
| Full Company Name: | Years in Business: | |||||
| Street Address: | ||||||
| City | State: | Zip | ||||
| Billing Address: | ||||||
| City: | State: | Zip | ||||
| Telephone: | Fax: | A/P Contact Name | ||||
| Are you EDI capable? Yes No | ||||||
| If yes, 850 P.O., 810 Invoice, 820 Remittance | ||||||
| Business Structure | ||||||
| Corporation | Proprietorship | Partnership | Other | |||
| If Incorporated: State of incorporation Year of Incorporation : | ||||||
| Subsidiary? Yes No | Division? Yes No | |||||
| If yes, Name & Address of Parent Company | ||||||
| Dun # | Tax ID # | |||||
| Has business/officer ever filed for bankruptcy? Yes No | ||||||
| If yes, when Chapter:7 Chapter:11 Chapter:13 | ||||||
| Name of Principal(s) | Title | ||||
| 1. | |||||
| 2. | |||||
| 3. | |||||
| Bank and or Lender References (list all secured parties) | |||||
| Name, Address Contact Name | Phone | Account# | |||
| 1. | |||||
| 2. | |||||
| 3. | |||||
| Trade References | |||||
| Name and Address | Phone | Fax | |||
| 1. | |||||
| 2. | |||||
| 3. | |||||
| 4. | |||||
| I/We agree to make all payments within our 30 day terms with Pennsylvania Machine Works, Inc. If it becomes necessary to file a lien, suit or engage a collection agency or attorney, I/We agree to bear all expenses incurred (whether or not suit is filed), including but not limited to attorney fees, court costs, and a 1-1/2% interest charge per month on all disputes goverened by the laws of Pennsylvania. | |||||
I hereby release any and all credit or financial information to Pennsylvania Machine Works, Inc.; by providing my e-mail address, or signing I am accepting your conditions of sales and testifying the above information is true to the best of my knowledge. |
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| E-mail address(required) | Name | Title | Date |
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