Komelon USA - Credit Application

Customer Information

Bill To

Bill To Address

Street Address Address Line 2 City State Postal / Zip Code

Phone

A/P Contact

Ship To

Ship To Address

Street Address Address Line 2 City State Postal / Zip Code

Fax

Buyer

Business Information

Business Type

Year Established

Owner/President

Federal ID #

Tax Exempt/Resale #

Website Address

Email Address

Bank Information

Bank Name

Address

Street Address Address Line 2 City State Postal / Zip Code

Checking Acct #

Phone

Contact

Business Credit Reference

We require at least 4 trade references to complete a credit application. Thank you

Reference #1

Name

Address

Street Address Address Line 2 City State Postal / Zip Code

Phone

Fax

Account

Reference #2

Name

Address

Street Address Address Line 2 City State Postal / Zip Code

Phone

Fax

Account

Reference #3

Name

Address

Street Address Address Line 2 City State Postal / Zip Code

Phone

Fax

Account

Reference #4

Name

Address

Street Address Address Line 2 City State Postal / Zip Code

Phone

Fax

Account

Signature

I certify that all information on this form is correct. I hereby authorize the release of any and all credit information by our bank and trade references necessary for the process of obtaining a line of credit with Komelon USA Corporation.

Signature

Date