Credit Application

Contact Information

Credit Amount Required *

Company Name *

Telephone *

Email *

Shipping Information

Shipping Address Line 1 *

Shipping Address Line 2

City *

State *

Zip Code *

Country *

Billing Information

Billing Address Line 1 *

Billing Address Line 2

City *

State *

Zip Code *

Country *

Payments Mailed From

Payments Address Line 1 *

Payments Address Line 2

City *

State *

Zip Code *

Country *

Other Information

Year Business Started *

Federal Tax Number *

Number of Employees *

Sales Tax Exempt Number

Will you authorize verbal purchase orders? *

Yes

Do you use a corporate credit/purchase card? *

Yes

If yes to the corporate card, what type?

if yes to the corporate card, what is the account number?

Ownership / Employee Contacts

Preferred Freight Lines

What type of business is this? *

If this is a subsidiary of another company, please list the parent company name and address:

Parent Company Address

Parent Company City

Parent Company State

Parent Company Zip

List all affiliated company trademarks:

Owner 1 Name:

Owner 2 Name:

Chief Financial Officer:

Purchasing Agent:

Accounts Payable:

Banking Institution Reference Number 1

Company Name:

Phone:

Fax:

Contact:

Company Name:

Banking Institution Reference Number 2

Phone:

Fax:

Contact:

Trade Reference Number 1

Company Name:

Phone:

Fax:

Contact:

Trade Reference Number 2

Company Name:

Phone:

Fax:

Contact:

All statements are true and accurate to the best of my knowledge. I authorize Lenz Inc. to make any and all inquiries necessary for action on this credit application. I fully understand the terms of NET 30 DAYS and the conditions of this application.

Authorized By: *

Title *