COTSWOLD INDUSTRY - CREDIT APPLICATION

ACCOUNT INFORMATION - Fill out below

ACCOUNT NAME:

Name of Person Filling Out This Form:

Year Incorporated:

# of Employees

BILL-TO COMPANY:

Street:

City/State/ZIP:

Phone #:

DUNS #:

SHIP-TO COMPANY:

Street:

City/State/ZIP:

Fax #:

E-mail:

BANKING REFERENCE #1 (required)

Name of Bank:

Address:

Phone #:

Fax #:

Name of Contact:

E-mail:

BANKING REFERENCE #2

Name of Bank:

E-mail:

Address:

Phone #:

Fax #:

Name of Contact:

TRADE REFERENCE #1 (required)

Name of Company:

Address:

Phone #:

Fax #:

Name of Contact:

E-mail:

TRADE REFERENCE #2

Name of Company:

Address:

Phone #:

Fax #:

Name of Contact:

E-mail:

TRADE REFERENCE #3

Name of Company:

Address:

Phone #:

Fax #:

Name of Contact:

E-mail:

TRADE REFERENCE #4

Name of Company:

Address:

Phone #:

Fax #:

Name of Contact:

E-mail:

TRADE REFERENCE #5

Name of Company:

Address:

Phone #:

Fax #:

Name of Contact:

E-mail:

TRADE REFERENCE #6

Name of Company:

Address:

Phone #:

Fax #:

Name of Contact:

E-mail: