Engineered Composite Materials | Application for Credit

Please print out the form below, complete and fax to
Credit Department, 112 Washington Street, East Walpole, Massachusetts 02032
Telephone (508) 668-0295 * Fax (508) 668-8762

Parts A, B, and D must be completed. You must attach a separate list of references as a substitute for Part C. This information will be held in the strictest confidence.

A)
Date:
Corporation:
Partnership:
Sole Proprietor:
Estimated Credit Requirements:
B)
Business Name:
Address:
City:
State or Province:
Zip Code:
Telephone:
Fax:
Principal(s) / Owner(s):
Title:
Home Address:
City:
State or Province:
Zip Code:
Division or Subsidiary of:
Years in Business:
Line of Business:
Annual Sales:
Name of Bank:
Account #:
Address:
Telephone:
Contact Name:
C)
Trade References:
Please list three major suppliers with whom you have established accounts. Please include telephone number, fax number and account number.
1. Name :
Account #:
Address:
Telephone:
Fax:
Contact:
2. Name :
Account #:
Address:
Telephone:
Fax:
Contact:
3. Name :
Account #:
Address:
Telephone:
Fax:
Contact:
D)
I certify the above information true and correct.
Owner / Principal signature:
Date:

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