CREDIT APPLICATION
Terms Net 30

Company Information
 
Years in Business:
Type of Company:  ProprietorshipPartnershipCorporationLLC
Full Legal Name:
Address: 
City: State:Zip:
Phone: 
Fax Number: 
Mobile Phone: 
Email Address: 
Mailing Address & Zip: 
Description of Business: 
Comments: 

Credit History  (Bankruptcies Within 3 Years Need Not Apply)
Previous Bankruptcies:  YesNo
If Yes - Date Filed:  Date Discharged:
If Yes - Provide Details: 
Previous Collections:  YesNo
If Yes - Provide Details: 
Previous Charge Offs:  YesNo
If Yes - Provide Details: 
Previous Judgments:  YesNo
If Yes - Provide Details: 
Explain All Previous
Credit Problems Not
Mentioned Above: 

Principals of Company: Owner, Partners, President etc.
Full Name & Title: 
Home Address & Zip: 
Home Phone:  Social Security No:
Residence:  OwnRent   No of Years:   Monthly Payment:
Mortgage Company: 
Account Number:  Phone:

Full Name & Title: 
Home Address & Zip: 
Home Phone:  Social Security No:
Residence:  OwnRent   No of Years:   Monthly Payment:
Mortgage Company: 
Account Number:  Phone:

Full Name & Title: 
Home Address & Zip: 
Home Phone:  Social Security No:
Residence:  OwnRent   No of Years:   Monthly Payment:
Mortgage Company: 
Account Number:  Phone:

Bank References  (2-Year History Required)
Bank's Name: 
Address & Zip: 
Acct Type:  Acct No: 
Phone:  Contact: 

Bank's Name: 
Address & Zip: 
Acct Type:  Acct No: 
Phone:  Contact:

Bank's Name: 
Address & Zip: 
Acct Type:  Acct No: 
Phone:  Contact: 

Finance and Trade References 
Company's Name: 
Address & Zip: 
Acct No: 
Phone:  Contact:

Company's Name: 
Address & Zip:
Acct No: 
Phone:  Contact: 

Company's Name: 
Address & Zip: 
Acct No: 
Phone:  Contact: 

Statement of Understanding and Authorized Signature
I hereby represent and warrant that I am duly authorized by all necessary action to execute this application request on behalf of my company. I agree that when I type my name, in the text box below, that for all intent and purposes I will be providing my legal signature over the internet to US Financial Group. I further agree that the legal ramifications are the same as if I actually signed this request in the presence of a US Financial Group representative. 

This application is given for the purpose of obtaining credit. I grant permission to US Financial Group to obtain a personal credit report (bureau) on all of the individuals that are listed above. I understand that individual credit histories may be a determining factor in the evaluation of this application.

I understand and agree that you may assign or transfer this credit application and that you may communicate the information contained herein to others to decide whether or not to extend credit.

I authorize the bank and business references listed above, as well as any of my/our lessors, landlords and any other past or present creditors to give any and all necessary information to you, or to your assignees or transferees, which will assist you in your credit inquiry.

I hereby certify under penalty of law that all of the foregoing information is true.

Please note: This application will "not" be processed by US Financial Group unless you have typed your name and title below, which comprises your electronic signature for internet transmitted documents.
 
(Type: Full Legal Name, Title)


1 YEAR WARRANTY ON ALL EQUIPMENT
FAX PURCHASE ORDER TO 719-687-6115

Prices subject to change, call for current inventory. Visa, Master Charge, American Express & COD welcome.
Orders placed by 4:00 P.M. will ship the same day.

800-530-8014    719-687-6082     (FAX) 719-687-6115
P.O. Box 5372 Woodland Park CO 80866 Ship 2314 Rampart Range Rd., Woodland Park CO 80863  Email sales@coloradotelephone.com

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