226 High St., Randolph, MA 02368 Phone: 781-986-3905 Fax: 781-986-3906

Credit Application - please complete and return to Fax (800) 393-1782

LEGAL BUSINESS NAME: ______________________________________________________________ Address: ______________________________________________________________________________ City: __________________________________________ State: ___________________ Zip: ___________ Phone: (____)_________________________________ Fax: (____)________________________________ Equipment Location: (If different from above)___________________________________________________ _____________________________________________________________________________________
Proprietorship: ________________ Partnership: __________________ Corporation: _________________	Years in Business: __________________ Federal I.D. Number: _______________ Type of Business: __________________
PRINCIPAL/OWNER NAME: ___________________________________ Title: _____________________ Home Address: ________________________________________________ SS# _____________________ City: ________________________________ State: ___________________ Zip: _____________________ PRINCIPAL/OWNER NAME: ___________________________________ Title: _____________________ Home Address: ________________________________________________ SS# _____________________ City: ________________________________ State: ___________________ Zip: _____________________
EQUIPMENT: _________________________________________________________________________ Price: $_________________________ Term: _______________________________________ months SUPPLIER NAME: ______________________________________ Phone: (____)____________________ Address: _______________________________________________ Salesman: ______________________ City: ________________________________ State: ___________________ Zip: _____________________
BUSINESS REFERENCES:
Bank Name: _____________________________________ Phone: (____)___________________________ Account Number: _________________________________ Bank Contact: __________________________ Type Account: _________________ Opening Date: ___________________ Average Balance: ___________ Bank Name: _____________________________________ Phone: (____)___________________________ Account Number: _________________________________ Bank Contact: __________________________ Type Account: _________________ Opening Date: ___________________ Average Balance: ___________ Business Trade References (Please provide 3) Name: _______________________ Phone: (____)_____________ Contact/Acct. #: ___________________ Name: _______________________ Phone: (____)_____________ Contact/Acct. #: ___________________ Name: _______________________ Phone: (____)_____________ Contact/Acct. #: ___________________
By signing below, the undersigned certifies that the above information given for purposes is true and correct. The undersigned authorizes the firm or person to whom this application is made and/or its assigns or any credit bureau or investigative agency to investigate the references, including bank, statements or other data listed or accompanying this application. The undersigned authorizes all parties contacted to release information requested as a part of said investigation. A fax or photocopy of this authorization shall be valid as the original. X____________________________________________________________________________________
Authorized signature Title Date