Customer Credit Application

Brian's Auto Glass Inc
430 Stephenson Ave, Escanaba, MI 49829
4 Industrial Park Drive, Negaunee, MI 49866

Customer Credit Application

Name of Applicant *

dba

Street Address *

City *

State *

Zip Code *

Phone *

Fax

Year Established *

Federal Tax ID *

State Resale or Exemption No.

Public or Private Corporation

Public Corporation

Private Corporation

State of Corporation

Date of Incorporation

Are you a subsidiary or a division?

Subsidiary

Division

Parent Company Name

Parent Company Street Address

Parent Company City

Parent Company State

Parent Company Zip Code

Will the Parent Company guarantee debts?

Requested Terms *

Amount

Accounts Payable Contact *

Accounts Payable Phone *

Accounts Payable Fax

Accounts Payable Email *

Credit References

Creditor 1

Account No.

Year Opened

Street Address

City

State

Zip Code

Creditor 2

Account No.

Year Opened

Street Address

City

State

Zip Code

Creditor 3

Account No.

Year Opened

Street Address

City

State

Zip Code

Purchasing Information

Does your company employ a Purchase Order Number system?

Verbal or Written?

List All persons authorized to make purchases

Billing Information

Billing Street Address *

Billing City *

Billing State *

Billing Zip Code *

Billing Phone *

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