Sample Credit Application Form

Please complete, attach financial information and return signed original by mail to:

Attn: Credit Manager




1) Organizational Information

Organization Name: __________________________________ Federal ID#: _____________

Billing Street Address: __________________________________________________________

Billing City: ___________________ County: ___________State: _________ Zip: ___________

Type of business: ___________________ No. Employees: ______ Year opened: ___________

Annual Revenue: $______________ Has co. ever filed bankruptcy: ___Yes ___No

Phone: ____________________________ Fax: ___________________

Web Site: ______________________________

2) Primary Contacts


Position Name Phone #/Extension/Email
PRESIDENT/Mgr Partner    
VP Finance/Controller    
Mgr Accounts Payable    
Purchasing Manager    
CIO/Manager IS System    

3) Your Purchase Authorization Policy

Your Order Authorization: ____ Only Verbal; _____ Only Written; _____ Mixed

4) Bank References


Bank Name & Address Account Numbers/ Type Acct/

Date Opened
Contact Name and Phone

5) Trade References


Firm Name & Address Product/Service (annual $ business) Contact Name and Phone

6) Open Credit Request:

Amount of Net30 Open credit requested: $ _______________

Note: Open credit account is not active until both approved by OUR Credit Manager and written notification of the amount and payment terms are received by Applicant.

The Ohio laws against discrimination require that all creditors make credit equally available to all credit worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

The furnishing of false information for the purpose of influencing our credit decision violates federal criminal laws and may subject a violator to fine, imprisonment or both.

The undersigned herby agrees that should a credit account be opened, and in the event of default in the payment of any amount due, and if such account is submitted to a collection authority, to pay an additional charge equal to the cost of collection including legal fees and court costs.

The undersigned individual who is either a principal or a sole proprietor of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from time to time as may be needed, in the credit evaluation process.


No failure on the part of YOUR COMPANY NAME to exercise any of its rights hereunder shall be deemed a waiver of any such rights or of any default. Demand, presentment, protests, and notice of dishonor, notice of protest, and notice of default are hereby waived.

The undersigned declares that the statements made herein are for the express purpose of obtaining a commercial credit account and are to the best of my/our knowledge and belief true and correct. The applicant understands that additional information if required in support of this application must be supplied before adequate consideration can be given to this application. The applicant consents to YOUR COMPANY making inquiries of such persons, firms or corporations, as it deems necessary in order to reach a decision on this application. It is further understood that the seller's normal terms are net 15 days, 1.5% per month compounded monthly charged on overdue accounts and that freight and insurance are for the buyer's account.

In consideration for YOUR COMPANY NAME advancing credit to the undersigned, the undersigned hereby personally unconditionally guarantees payment for all amounts advanced by way of credit to, and all amow1ts due or to become due hereunder, from the company.

This guarantee remains in effect until all amounts owed have been paid in full to YOUR COMPANY. Guarantor must pay all amounts owing under this guarantee when YOUR COMPANY NAME makes written demand. YOUR COMPANY NAME is not required to seek payment from any other source before demanding payment from guarantor.

Signature: ___________________________________________ Title: _______________

Please print your name: ________________________________ Date: _______________

Your address: _____________________________________________________________

Your Social Security No. ________________________________

7) Attach one copy of the latest financial statement [audited if available] to this application.

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