CREDIT APPLICATION

APPLICANT COMPANY INFORMATION

Company Name *

Address *

City *

Zip *

Phone *

Fax *

State *

President/CEO

A/P Contact

Principal Owner Name (if not Pres/CEO) *

Principal Owner Home Address *

Applicant Firm is : *

Corporation
Partnership
LLC
Proprietorship

Federal Tax ID # or Social Security # if a proprietorship

Corporation or LLC Formed:

State of Incorporation

BANK REFERENCE

Bank *

Account *

Address *

City *

State *

Zip *

Phone *

CREDIT REFERENCES

Company *

Account *

Address *

City *

State *

Zip *

Phone *

Fax

Contact

CREDIT TERMS AND CONDITIONS

Applicant warrants that the above information is true and accurate. I/we hereby authorize Clear Blue DEF LLC to contact the references to investigate Applicant’s credit and financial responsibility. I certify that on behalf of Applicant, I am familiar with the terms shown on “Terms and Conditions of Sale” page in Clear Blue DEF’ price list, and that failure to abide by the terms and conditions shown may result in interest and/or late fees being assessed to Applicant’s account