Confidential Credit Application

Address: United States
Telephone: +1

Date
MM slash DD slash YYYY
Name*
First Last
Name of your ChimFab Sales Rep
Business Name*
Address*
Street Address City State ZIP Code
Phone*
Email*
Website
Business Type
Check the Business Type of your business below
- Corporation
- Partnership (Limited)
- Partnership (General)
- LLC
- Proprietorship
- Other
If a corporation or LLC enter the State of formation below.
Federal ID #
Tax Exempt # (If applicable)
Are you listed in Dunn & Bradstreet?
- Yes
- No
Date Business Started (If less than 3 years old financial statement is required)
MM slash DD slash YYYY
Nature of Business
Accounts Payable Contact
Accounts Payable Phone
Email
Credit Limit Request per month $
Full Legal names of all Corporate Officers, General Partners, or Owners
Please hit the + sign to add more
Name Title
Credit References
Please add a minimum of 4 Credit references (Click on the the + sign to enter additional references)
Name Address City Phone Fax

Name	Title

Name	Address	City	Phone	Fax

Business Type