Credit Application

Corporation Name or Trade Style*

Address*

City*

State*
—Please choose an option—

Zip Code*

Phone*

Fax

Type of Organization*
CorporationPartnershipIndividual

Are you tax exempt?*
YesNo

Tax Exempt Form

Type of Business

Date Established

Principal Officers*

Do you issue purchase orders?
YesNo

Purchasing Agent or Manager

Name of each person and title authorized to make purchases

Name of official and title responsible for payment of account

Rental Yard Credit References

• 1st Reference

  Name
  

  Street
  

  City
  

  State
  —Please choose an option—

  Zip Code
  

  Phone
  

  E-mail
  

  Type of Account
  

  Length of Relationship
  

• 2nd Reference

  Name
  

  Street
  

  City
  

  State
  —Please choose an option—

  Zip Code
  

  Phone
  

  E-mail
  

  Type of Account
  

  Length of Relationship
  

• 3rd Reference

  Name
  

  Street
  

  City
  

  State
  —Please choose an option—

  Zip Code
  

  Phone
  

  E-mail
  

  Type of Account
  

  Length of Relationship
  

• 4th Reference

  Name
  

  Street
  

  City
  

  State
  —Please choose an option—

  Zip Code
  

  Phone
  

  E-mail
  

  Type of Account
  

  Length of Relationship
  

Bank Account Details

• 1st Reference

  Name
  

  Street
  

  City
  

  State
  —Please choose an option—

  Zip Code
  

  Phone
  

  E-mail
  

  Type of Account
  

• 2nd Reference

  Name
  

  Street
  

  City
  

  State
  —Please choose an option—

  Zip Code
  

  Phone
  

  E-mail
  

  Type of Account
  

In consideration for granting of credit by Voorhees Hardware & Rental Inc., we agree to the following*
YesNo

Dated this day*

Customer Name*

Title*

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