Please fill out the below form in its entirety to be considered for a credit approval. Our credit manager will notify you of your approval in a timely manner. All information provided will be held in strictest confidence.
FIRM INFORMATION
Name of firm or individual
Street address
City
StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
ZIP
Area code
Phone
Years at this address0-55-1010-1515-2020+
OWNERSHIP
Ownership typeCorporationPartnershipIndividualIncorporated in past 12 months
Name of Principal 1
Name of Principal 2
Name of Principal 3
Name of Principal 4
FINANCES
Bank
Bank Phone
Bank officer or department
Bank address
REFERENCES
Business name
Business address
Second business name
Third business name
Fourth business name
Are cash sales okay until credit is approved? YesNo
How did you hear about Allentown Optical?*Returning customerGoogle searchOnline advertisementPrinted advertisementSocial mediaReferral
We certify that all the information on this form is correct. We fully understand your credit terms and agree to the proper payment in consideration of extended credit.
Electronic signature:
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