Date  Company Name 
Address 
 City   State   Zip 
 Accounts Payable Contact 
Phone No.  Fax No.
Years in Business     Years at Present location 
Type Of Business   F.I.N. 
Illinois Resale No.   P.O. Required YES NO
Proprietorship  Partnership  Corporation                 

Principal Officers:
Name:  Position
Address: City: State:
Name:  Position:
Address: City: State:

          

Amount of Credit Requested $500.00$1000.00$1500.00$2000.00$2500.00

LIST THREE BUSINESS REFERENCES:

Name 
Address 
Phone Acct. No.

Name 
Address  
Phone Acct. No.

Name 
Address  
Phone Acct. No.
                   

Persons Authorized to Sign for Rentals:
Name:Position:
Name:Position:
Name:Position:
Name:Position:
            

Special Billing Instuctions:


                  

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