Please provide the following contact information:

Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Please Enter Your Shipping Address

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Name of Contact Person

Owners Name

Type of business

Date Established

-- mm/dd/yy
 

Type of Entity. Select One.

Proprietorship Established Partnership Corporation Other
 

State of Incorporation

Date of Incorporation

-- mm/dd/yy
 

If Non-Taxable, Please provide applicable tax number

Bank Information

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Bank Phone Number

Bank Officer

Bank Account Number

Trade Reference 1

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Trade Reference 2

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Trade Reference 3

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Estimated Annual Purchases

Credit Limit Requested

 

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The above information is provided for the purpose of extending credit to the company applying on Goodwin Tucker Group's terms of Net 10. To the best of our knowledge and belief, the information is accurate and may be relied upon in making your credit decision. We authorize our bank and suppliers to furnish Goodwin Tucker Group any information necessary to complete your evaluation of our credit history. The customer will be liable for any costs incurred in the collection of past due accounts, including attorneys fees, whether or not a suit is filed. Charging purchases to an open account constitutes acceptance of Goodwin Tucker Group's terms.

Enter your name and title below acknowledging this statement

Your Name

Your Title

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