Please fill out the following form completely and submit to be evaluated for credit.

General Information

Desired Credit Limit:
Company Name:
D/B/A:
Bill to Address:
Street Address:
City/State:
Zip Code:
Owner(s)/President:
Accts. Payable Contact:

AP Phone & Fax #:
AP E-mail Address:
Banking Institution:
Acct. Numbers:
Phone & Fax #'s:
Years in Business:
Federal Tax ID #:
Company Structure:

References

Name Of Company:
Contact:
City/State:
Phone:

Name Of Company:
Contact:
City/State:
Phone:

Name Of Company:
Contact:
City/State:
Phone:

Authorization

I authorize the release of the above information to Steven Enterprises Inc. for credit purposes only. In order for Steven Enterprises Inc. to grant me credit, I give permission for my credit to be checked as required for that purpose. Credit terms are net thirty (30) days from the date of invoice. Interest will be charged at 1.5% per month on items over thirty (30) days. If my account is referred for collection, I agree to pay all billing and collection costs and a reasonable attorney's fee. All the above is true and terms are accepted.

Print Officer's Name:
Officer's Signature:
Officer's Title: