CREDIT REFERENCE FORM

CONTACT INFORMATION	BILLING INFORMATION
CONTACT NAME	CONTACT NAME
COMPANY NAME	COMPANY NAME
ADDRESS	ADDRESS
PHONE	PHONE
FAX	FAX
EMAIL	EMAIL
GENERAL COMPANY INFORMATION
FEDERAL TAX ID NO.	PRINCIPAL OFFICER
OTHER ID	TITLE
LEGAL STRUCTURE select all that apply
Corporation	LLP
Partnership	Sole Proprietor
LLC	Non-Profit
IN BUSINESS SINCE	TYPE OF BUSINESS
STATE TAX ID	RESELLER NO.
BANK REFERENCES
BANK 1 NAME	BANK 2 NAME
ACCOUNT NO.	ACCOUNT NO.
ACCOUNT TYPE	ACCOUNT TYPE
BANK 1	BANK 2
ADDRESS	ADDRESS
CONTACT	CONTACT
FAX	FAX
PHONE	PHONE
TRADE REFERENCES
COMPANY 1	COMPANY 1
CONTACT	ADDRESS
PHONE
FAX	EMAIL
COMPANY 2	COMPANY 2
CONTACT	ADDRESS
PHONE
FAX	EMAIL
COMPANY 3	COMPANY 3
CONTACT	ADDRESS
PHONE
FAX	EMAIL

REFERENCE CHECK CONDUCTED BY	ADDRESS
COMPANY NAME
PHONE

AUTHORIZATION
The signature below represents and warrants that (a) the party signing below is an authorized representative of the company; and (b) that the information provided herein is a complete and accurate representation of the company's financial situation as of the date hereof. Any misrepresentation or fraudulent information provided will be the basis for default under this agreement. By signing this form, I expressly authorize the company listed above to contact the above references to determine credit worthiness.
SIGNATURE	DATE
PRINTED NAME	BUSINESS TITLE

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