Business Name ________________________________
Billing Address _________________________________
City, State, and Zip ____________________________
Phone____________
Street/Shipping Address _________________________ Fax Number____________
Fed. ID# or SS# _____________
Proprietorship__
Partnership__ Corporation__
Years in business_____ Monthly credit limit requested $_________
Have you or any of the principles in your
company ever declared bankruptcy?___________
Proprietors, Partners, or Officers
Name______________________Title_____________Address______________________
Name______________________Title_____________Address______________________
Subsidiaries, Affiliates, Parent Companies, or DBA________________________________
Bank References
Name_____________________________________Phone(
) Account#s_________________________________Loan Officer_____________
Trade References
1)Trade Reference__________________________________Phone(
)_______________ Address________________________________________
City, State and Zip_______________________________
Account Number ________________
2)Trade
Reference__________________________________Phone( )________________ Address________________________________________
City,
State and Zip_______________________________
Account Number ________________
3)Trade Reference__________________________________Phone(
)________________ Address________________________________________
City, State and Zip_______________________________
Account
Number ________________
4)Trade Reference__________________________________Phone(
)________________
Address________________________________________
City, State and Zip_______________________________
Account Number ________________
Applicant agrees to notify Quicksilver Engineering promptly of any changes in ownership of the business. Until Quicksilver Engineering
receives written notice of any changes in ownership, applicant agrees to accept liability for all charges to the business conducted
under firm name, regardless of Applicant's actual relationship with the new owner.
Applicant's signature attests
to applicant's financial responsibility and willingness to pay Quicksilver Engineering invoices. Applicant authorizes Quicksilver
engineering to investigate the references listed pertaining to applicant's credit and financial responsibility, and authorizes disclosure
of information relating to applicant's credit and financial responsibility to Quicksilver Engineering.
Signed by:______________________________Title*_____________Date_______
(President, Owner)
*Applications received without the signature of the President or Owner will be returned.
