Credit Application

Submit Your Credit Application

To arrange payment terms for your concrete pouring project, please complete the credit application below.

By filling out this form, you certify that you have the authority to execute this credit agreement on behalf of the business identified, and that the information submitted is true and correct.

Step 1 of 5

Business Name*
Line of Credit Requested
Phone*
Fax
Email*
Billing Address*
Street Address Address Line 2 City State ZIP Code
How long at this address?
Is your physical address different than your billing address?*
- Yes
- No
Shipping Address
Street Address Address Line 2 City State ZIP Code
D/B/A*
Federal Tax ID #*
Former Business Address (if applicable)
Street Address Address Line 2 City State ZIP Code
Type of Business
Date Established
How long in Business
Mortgage holder / Landlord
Address
Street Address Address Line 2 City State ZIP Code
Phone
Does State, County, or City require a License?
- Yes
- No
If Yes, License #

Trade References
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax*
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax*
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax*

Bank References
Name*
Contact*
Address*
Street Address Address Line 2 City State ZIP Code
Name
Contact
Address
Street Address Address Line 2 City State ZIP Code
Name
Contact
Address
Street Address Address Line 2 City State ZIP Code

Number of Employees
Estimated Annual Sales
Sales Area
Has the firm or any of its principals ever been Bankrupt?
- Yes
- No
If Yes, explain
Please provide a list of personnel authorized to place orders / charge to your account.
Any misrepresentation in this application will be considered evidence of fraud, since this information is the basis for the extending of credit. As an inducement to grant credit, the undersigned warrants that the information submitted is true and correct. You are authorized to investigate the credit references and principals listed.

In consideration for the extension of credit, said business promises to pay for all purchases within the terms agreed and agrees to pay a service charge per month of 1 1/2% per month (18% annual percentage rate) on all past due balances. In the event any third parties are employed to collect any outstanding monies owed by said business the undersigned agrees to pay reasonable collection costs, including attorney fees, whether or not litigation has commenced, and all costs of litigation incurred. The undersigned represents that he/she has the authority to execute this credit agreement on behalf of the business identified.
Name of Business*
Name*
First Last
Title*
Email*

Credit Application

Submit Your Credit Application

Step 1 of 5

Principals

Trade References

Bank References