CAROLINA LIQUID CHEMISTRIES CORP. CREDIT APPLICATION FOR A BUSINESS ACCOUNT
BUSINESS CONTACT INFORMATION
Title:
Company Name:			Contact:
Phone:		Fax:	Email:
Registered company address:
City:		State:	Zip Code:
Date business commenced:
Sole proprietorship:	Partnership:	Corporation:	Other:
BUSINESS AND CREDIT INFORMATION
Primary business address:
City:		State:	Zip Code:
How long at current address?:
Phone:		Fax:	Email:
Bank name:
Bank address:			Phone:
City:		State:	Zip Code:
Savings Account #
Checking Account #
Other:
FED Tax ID # / SS #
BUSINESS/TRADE REFERENCES
Company name:
Address:
City:		State:	Zip Code:
Phone:		Fax:	Email:
Type of account:
Company name:
Address:
City:		State:	Zip Code:
Phone:		Fax:	Email:
Type of account:
Company name:
Address:
City:		State:	Zip Code:
Phone:		Fax:	Email:
Type of account:
AGREEMENT
By selecting the "Submit" button, you are signing this Agreement electronically, and you are authorizing Carolina Liquid Chemistries Corp. to make inquiries into the banking and business/trade references that you have supplied
SIGNATURE(S)
AUTHORIZED SIGNATURE:		AUTHORIZED SIGNATURE:
PRINTED NAME:		PRINTED NAME:
TITLE:		TITLE:
DATE:		DATE: