Credit Application

Customer Name

Mailing Address

Street Address (if different)

City

State

Zip

Accounts Payable Contact

AP Phone

AP Fax

AP Email

Business Type

Corporation

Partnership

Individually Owned

Business Year and State

Number of Years in Business

Sales Tax Exempt No

*Please help us serve you more quickly by providing your Tax Resale Certificate. Note that orders cannot be shipped until the Resale Certificate is received. You may use the Uniform Sales & Use Tax Certificate for all states except Florida, Indiana, Louisiana, Massachusetts, Mississippi, New York, Virginia, West Virginia and Wyoming. Please use the state specific form for each of those states.

Officer / Owner Name(s)

Officer’s or Owner’s Name 1

Title 1

Officer’s or Owner’s Name 2

Title 2

Financial Reference:

Bank

Bank Address

Bank Phone

Bank City

Bank State

Bank Zip

Suppliers Who Have Granted You Credit:

Supplier Name 1

Supplier Acct No. 1

Supplier Address 1

Supplier Phone 1

Supplier Fax 1

Supplier Name 2

Supplier Acct No. 2

Supplier Address 2

Supplier Phone 2

Supplier Fax 2

Supplier Name 3

Supplier Acct No. 3

Supplier Address 3

Supplier Phone 3

Supplier Fax 3

The Uttermost Co. is authorized to contact the above bank and trade references regarding credit and financial information. In the event of default by your company, you agree to be liable for collection fees, court fees, and reasonable attorney fees. Applicant also agrees in the event of default that jurisdiction will be enforced in the courts of Franklin County, Virginia for any and all outstanding debts due by applicant and its successors.

Signature

By typing my name I agree to the terms of this document.

My Title

Date