CREDIT APPLICATION

Company Information:

Company Name:*

DBA Name:

Contact Name:*

Email:*

Phone:*

Ext #:

Fax:

Billing Information:

Billing Address:*

City:*

ZIP:*

Contact Name:*

Email:*

Phone:*

Ext #:

Fax:

Shipping Information:

Shipping Address:*

ZIP:*

Contact Name:*

Email:

Phone:*

Ext #:

Fax:

Business & Credit Information:

Years In Business:*

# of Employees:*

Type of Business:*

Corporation:

Sub S Corp:

C Corp:

Partnership:

Sole Proprietorship:

Officers:

Officers of the Company:

Name:*

Title:*

Name:

Title:

Accounting:

Accounts Payable Name:*

A/P Phone:*

A/P Email:*

A/P Fax:

Bank Reference:

Bank Name:*

Contact Name:*

Account #:*

Phone:*

Ext #:

Bank Address:*

City:*

ZIP:*

Trade Reference:

Address:*

City:*

ZIP:*

Contact Name:*

Email:*

Phone:*

Ext #:

Fax:

Trade Reference:

Address:

City:

ZIP:

Contact Name:

Email:

Phone:

Ext #:

Fax:

Trade Reference:

Address:

City:

ZIP:

Contact Name:

Email:

Phone:

Ext #:

Fax:

Trade Reference:

Address:

City:

ZIP:

Contact Name:

Email:

Phone:

Ext #:

Fax:

By submitting this application, you authorize Valriya to make inquiries into the banking, business, and trade references that you have supplied in obtaining a credit review and is warranted to be true.

I/We herby authorize Valriya to investigate the references cited, pertaining to my/our credit and financial responsibility.

I further agree to pay to the terms cited on each Valriya invoice presented.

CREDIT APPLICATION

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