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General Information
Applicant Business Name:
Applicant Business Taxpayer ID Number (EIN or SSN):
Dun and Bradstreet Number (if known):
Primary Contact:		Business Fax Number:
Contact Telephone:		Contact Email:
Physical Business Address:
Street Address:		City:
State:		Zip Code:
Business Billing Address (if different):
Street Address:		City:
State:		Zip Code:

Commercial References

Contact Name	Business Address	Telephone	Fax
1
2
3
4

Business Principals

Principal Name	Title	Ownership %	Home Address	Home Telephone
1
2
3
4

Business Description		Bank Reference
Registered in :	Date Registered:	Banking Institution :
Type of Entity:		Type of Financial Account:
Business Category:		Street Address:
Annual Sales (gross):		City:
Accounts Payable Contact:		State:	Zip Code:
Accounts Payable Phone:

In completing this credit application, I acknowledge as the owner of the applying business that all credit application information is true and correct. Pacific Coast Breaker, Inc is authorized to obtain any required credit reports on the applicant and/or owners.

"Yes I acknowledge that I accept the Terms and Conditions of sale"


Name	Title

rev. 04/06/05

Credit Application

To download a printable version of the application click here