Bluegrass International Credit Application

Applicant Information

Name of Company

Years In Business

Billing Address

City

State

Zip

Shipping Address

City

State

Zip

Contact Email Address

Website

Telephone

Fax

Principal Type of Business

Business Is a

Individual Business
Corporation
Partnership
Limited Partnership

Federal ID #

or Social Security #

Amount of Credit Desired

Purchase Order Numbers

Will Be Furnished
Will Not Be Furnished

Sales Tax Status

Taxable
Exempt

Tax Exempt #

Company DOT #

Insurance Carrier’s Name

Carrier’s Phone Number

Principal Owners Or Officers

Name

Title

Home Address

Social Security #

Phone Number

Fax Number

Email Address

Name

Title

Home Address

Social Security #

Phone Number

Fax Number

Email Address

Bank Reference

Must have account number.

Bank Name

Contact Name

Address

City

State

Zip

Account Number

Phone Number

Fax Number

Email Address

Trade References

Must list three businesses you have an active convenience account with. Not Credit Cards, Utilities or Buy Here/Pay Here. To expedite account approval, please contact your references and ask them to return the Reference Request as soon as possible.

Trade Reference

Contact Name

Address

City

State

Zip

Account Number

Phone Number

Fax Number

Email Address

Trade Reference

Contact Name

Address

City

State

Zip

Account Number

Phone Number

Fax Number

Email Address

Trade Reference

Contact Name

Address

City

State

Zip

Account Number

Phone Number

Fax Number

Email Address

Signature

By typing my name into the field below, the undersigned certifies that the information given above is true and complete and authorizes Bluegrass International, its subsidiaries and their assigns or potential assigns, or any other lender that this application is submitted to, to investigate the above information and the undersigned's accounts and credit experience. Bluegreass International credit experience and account information on the undersigned. This shall be a continuing authorization for all present and future disclosures of account information and credit experience on the undersigned by Bluegrass Internaional, or any person requested to release such information to Bluegrass International.

Signature

Date

Please enter the text from the image, without spaces. Letters are not case-sensitive.

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