Hackworth Reprographics, Inc. - Professional Imaging Solutions

Credit Application

Legal Name:

T/A or DBA Name:

Street Address:

Shipping Address:

Billing Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

E-Mail Address:

* Website:

Federal Tax ID Number:

Dun & Bradstreet Number:

Ownership Type:

* Specify Other:

If Corporation, List State:

Date of Incorporation:

Registered Agent:

Reg. Agent Address:

Type of Business:

Date Established:

Payables Contact:

* Number: *

Email: *

Purchasing Contact:

* Number: *

Email: *

Exempt from Sales Tax? * State: Sales Tax Exemption Number:

Do you require Purchase Orders? *

*If so, it is the customer's responsibility to supply PO number or job number when order is placed.


Owners and/or Officers
Name: *	Title: *
Address, City & State: *	SSN#: *

Name: *	Title: *
Address, City & State: *	SSN#:
Has the company ever declared bankruptcy: *	If so, date filed:

Bank Reference
Bank Name: *	Phone Number: *
Address, City & State: *	Fax Number : * Account #: *
Account Type: *	Contact Name & Position: *

Credit References (List Three)
1. Company Name: *	Phone Number: *
Address, City & State: *	Fax Number : Contact: *
Account #:

2. Company Name: *	Phone Number: *
Address, City & State: *	Fax Number : Contact: *
Account #:

3. Company Name: *	Phone Number: *
Address, City & State: *	Fax Number : Contact: *
Account #:


I have read the General Conditions. I hereby agree to all credit terms and conditions attahced, and give permission for you to contact the above listed references and/or request credit reports from Equifax Information Services, Inc. on Company and Principles.*

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