AC1 SUPPLY, INC.

CREDIT APPLICATION

6504 N.W. 77h Court, Miami, Fl 33166 * Phone: (305) 556-6251 * Fax: (305) 556-6256

COMPANY OR INDIVIDUALS NAME

FEDERAL I.D. NUMBER

SOCIAL SECURITY NUMBER

COMPLETE ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE#

Fax#

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP CODE

AMOUNT OF CREDIT REQUESTED

NATURE OF BUSINESS

TYPE OF BUSINESS

GENERAL CONTRACTOR

CORP.

INDV.

OTHER

TAXABLE:

YES

NO

IF NOT, YPUR SALES TAX #

PERSON IN CHARGE OF PAYMENTS

THIS SECTION MUST BE FILLED OUT COMPLETELY, GIVE FULL NAME AND HOME ADDRESS OF INDIVIDUAL AND IF A FIRM OF EACH PARTNER, OR IF A CORPORATION, OF EACH OFFICER AND OFFICEHELD BY EACH

NAME

SOCIAL SECURITY #

POSITION

HOME ADDRESS

CITY

STATE

ZIP CODE

PHONE #

NAME

SOCIAL SECURITY #

POSITION

HOME ADDRESS

CITY

STATE

ZIP CODE

PHONE #

NAME

SOCIAL SECURITY #

POSITION

HOME ADDRESS

CITY

STATE

ZIP CODE

PHONE #

CREDIT REFERENCE

COMPANY NAME

ADDRESS

CITY

STATE

ZIP CODE

TYPE OF BUSINESS

BALANCE OWED

PHONE

FAX

CONTACT

COMPANY NAME

ADDRESS

CITY

STATE

ZIP CODE

TYPE OF BUSINESS

BALANCE OWED

PHONE

FAX

CONTACT

COMPANY NAME

ADDRESS

CITY

STATE

ZIP CODE

TYPE OF BUSINESS

BALANCE OWED

PHONE

FAX

CONTACT

COMPANY NAME

ADDRESS

CITY

STATE

ZIP CODE

TYPE OF BUSINESS

BALANCE OWED

PHONE

FAX

CONTACT

BANK REFERENCE

NAME

ADDRESS

CITY

STATE

ZIP CODE

PHONE

FAX

ACCOUNT #

CONTACT

NAME

ADDRESS

CITY

STATE

ZIP CODE

PHONE

FAX

ACCOUNT #

CONTACT

Initials

Print

next page >>