Customer App - Brunner & Lay

Name (As account will be carried)*

Headquarters Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Accounts Email*

Type of Business*

Fax No

Number of Employees

At present location since*

Company Structure*

Date Incorporated*

If Corporation or Partnership or Joint Venture, list principles or partners names, titles, and addresses*

BRIEF HISTORICAL BACKGROUND of Individual Applicant or Principal Officer if Corporation, or General Partner if Partnership:*

Bank Name*

Bank Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank Officer

First Last

Bank Account Number

Bank Phone Number*

Give only names of those you buy from on open account

Business Reference 1*

First Last

Business Phone 1*

Business Fax 1

Business Reference 2*

First Last

Business Phone 2*

Business Fax 2

Business Reference 3*

First Last

Business Phone 3*

Business Fax 3

Amount of Credit Requested (on a monthly basis) in $*

(This is an application for credit only. Our terms are net 10th prox) (Interest will be charged on all accounts sixty (60) days past due.)

Is your company tax exempt?*

Yes
No

If yes please attach a properly executed Exemption Certificate.

Max. file size: 50 MB.

Incorporated under laws of what State*

Previous entity (if any) prior to incorporation*

Has credit been established previously with this company or affiliates?*

Yes
No

If so, under what trade style?

Is this company a subsidiary of another company?

Yes
No

If yes, please name the other companies with which affiliated:

Has this company ever filed bankruptcy either individually or as an associated company?*

Yes
No

If you have declared bankruptcy, please define

Is there any pending Suits, Liens, or Judgements against this company?*

Yes
No

If there are pending Suits, Liens, or Judgements, please define

Financial Summary as of*

Current Assets ($)*

Current Liabilities ($)*

Net Worth ($)*

Annual Sales Net ($)

Gross Profit ($)

Operating Expenses ($)

Net Profit ($)

Please lend support to the above credit request and financial summary by attaching a copy of your most recent Financial Statement or a copy of your IRS form 1120 for the latest fiscal year end with all attachments. This information is for the sole purpose of granting credit and will be held in the strictest of confidence. Submit*

Max. file size: 50 MB.

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