Credit Application Form – Clean Water of New York, Inc

COMPANY NAME

ADDRESS

CITY, STATE & ZIP CODE

CONTACT

PHONE

EMAIL ADDRESS

TYPE OF BUSINESS

CORPORATION PARTNERSHIP LLC

IF INCORPORATED (HOW MANY YEARS)

HOW MANY YEARS IN BUSINESS

FEDERAL ID NUMBER

OFFICER NAMES & TITLES

BANK NAME

BANK ACCOUNT NUMBER

BANK ADDRESS

BANK CONTACT PERSON

BANK PHONE NUMBER

TRADE REFERENCE 1 (COMPANY NAME)

COMPANY ADDRESS

COMPANY CONTACT PERSON

COMPANY PHONE NUMBER

TRADE REFERENCE 2 (COMPANY NAME)

COMPANY ADDRESS

COMPANY CONTACT PERSON

COMPANY PHONE NUMBER

For the purpose of obtaining credit on an open account, (We) I hereby attest that the information above is presented accurately and understand that Clean Water of New York, Inc.’s normal terms are net 15 days from invoice date and that Clean Water of New York may suspend terms in the event of past due accounts.

PRINT NAME

TITLE