DGP Open Account
Credit Application
Please Print and Fax this form
to: 219-462-9333
OPEN ACCOUNT CREDIT APPLICATION
FIRM NAME: _________________________________________________________
PHONE: _____________________________________________________________
FAX: ________________________________________________________________
BILLING ADDRESS: ___________________________________________________
CITY, STATE, ZIP: _____________________________________________________
SHIPPING ADDRESS: __________________________________________________
CITY, STATE, ZIP: _____________________________________________________
( ) Individual ( ) Partnership ( ) Corporation
NAME OR PARENT CO. ( If Subsidiary ) ___________________________________
TYPE OF BUSINESS: _________________________ YRS. IN BUSINESS: ______
FEDERAL TAX NO.: ___________________________________________________
SOCIAL SECURITY NO.: _______________________________________________
PROPRIETOR, PARTNERS OR OFFICERS
NAME: _________________________________ TITLE: ______________________
NAME: _________________________________ TITLE: ______________________
NAME: _________________________________ TITLE: ______________________
INDIVIDUAL RESPONSIBLE FOR PAYMENT OF ACCOUNT
NAME: _________________________________ TITLE: ______________________
BANK REFERENCE
NAME: _________________________________ ACCT. NO.: __________________
ADDRESS: _______________________________ PHONE: ____________________
CITY/STATE/ZIP: _______________________ CONTACT: ___________________
TRADE REFERENCES
NAME: __________________________________ PHONE: ____________________
ADDRESS: ____________________________ CONTACT: ____________________
NAME: __________________________________ PHONE: ____________________
ADDRESS: ____________________________ CONTACT: ____________________
NAME: __________________________________ PHONE: ____________________
ADDRESS: ____________________________ CONTACT: ____________________
Applicants signature attests
financial responsibility, ability and willingness to pay our
invoices in 30 Days. If any suit or legal action is instituted in connection with any controversy arising out of the estimate, proposal, or any work authorized in connection with same, the prevailing party shall be entitled to recover, in addition to the court costs and disbursements, such sum as the court may adjudge reasonable as attorney fees.
The above information is for the purpose of obtaining credit and is warranted to be true.
I/We hereby authorize the firm to whom the application is made to investigate the references listed pertaining to my/our credit and financial responsibility.
COMPANY NAME: _________________________________________________
AUTHORIZED SIGNATURE: __________________________________________
POSITION: ________________________________________________________
