Credit Application
Company Information
Company Name:
Address:
City:
State:
Zip:
Mailing Address:
Telephone:
Fax:
Type of Business: Corporation
Partnership
Individual
This location since:
Date of Incorporation:
State Incorporated in:
Corporate Federal ID #:
Partnership/Individual ID SS #:
Tax Exempt #:
Dun & Bradstreet #:
Person(s) authorized to purchase:
Purchase order required:
Yes
No
Optional
Accounts Payable Contact:
Accounts Payable Phone:
Accounts Payable Fax:
If you are tax exempt, please submit an original tax exemption certificate to your sales representative.
References
Bank Reference
Bank Name:
Bank Account #:
Address:
City:
State:
Zip:
Telephone:
Fax:
Contact:
Trade
References
Company Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Person to contact:
Company Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Contact:
Company Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Contact:
MPC Sales Representative:
You have my permission to verify this information with these references:
Yes
No
Please type your name:
Today's date:
