3612 W. Truman Blvd

Jefferson City, Mo. 65109

[tel] 573-634-3177

[fax] 573-635-2016

APPLICATION FOR CREDIT

  Name of Firm or Individual_________________________________________________

  Address:_________________________   Phone #: ( ____ ) __________ Fax #: ( ____ ) __________

  City:__________________     State:______     Zip Code:________     Years At This Address:______

              The following information must be provided. It will be held in the strictest confidence.

  Taxable: Y/N  If No, please include tax exempt letter.

  Ownership:

    1. Name(s) of Principal(s)____________________________     Address:_________________________

        City:_______________     State:______     Zip:________     Phone: ( ____ ) __________

  Bank References:

        Bank:_________________________     Bank Address:_________________________

        Bank Officer or Department:_________________________    Phone #: ( ____ ) __________

  Trade References:

    1. Business Name:_____________________________     Address:_________________________

        City:_______________     State:______     Zip:________     Phone: ( ____ ) __________

    2. Business Name:__________________________     Address:_________________________

        City:_______________     State:______     Zip:________     Phone: ( ____ ) __________

    3. Business Name:__________________________     Address:_________________________

        City:_______________     State:______      Zip:________     Phone: ( ____ ) __________

    □       Check here if cash sales are okay until credit is approved.

  We certify that all the information on this form is correct. We fully understand your credit terms are
  Net 30 days and agree to the proper payment in consideration of extended credit.

  Date:___________ 20___      Signature:_________________________     Title:_____________________

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