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Company
Name __________________________________________________
Years In Business? ___________________
Address
_________________________________________________________
Fax Phone ( )
___________________
City
_______________________________ State _______ Zip _______________
Telephone ( )
__________________
[
] Proprietorship [
] Partnership
[ ] Corporation Federal
ID# ______________ Tax Exempt ID# ________________
List
name, home address and telephone number of principal owner(s)/officer(s).
Name
__________________________________________________________
Address
_________________________________________________________
Social Security #
__________________
City
_______________________________ State _______ Zip _______________
Telephone ( )
__________________
Name
__________________________________________________________
Address
_________________________________________________________
Social Security #
__________________
City
_______________________________ State _______ Zip _______________
Telephone ( )
__________________
Bank
Name
__________________________________________________________
Address
_________________________________________________________
Fax Phone ( )
__________________
City
_______________________________ State _______ Zip _______________
Telephone ( )
_________________
Checking
Account # __________________________
Savings/Line Of Credit Account # ____________________________
Suppliers
Name
__________________________________________________________
Address
_________________________________________________________
Fax Phone ( )
__________________
City
_______________________________ State _______ Zip _______________
Telephone ( )
_________________
Name
__________________________________________________________
Address
_________________________________________________________
Fax Phone ( )
__________________
City
_______________________________ State _______ Zip _______________
Telephone ( )
_________________
Name
__________________________________________________________
Address
_________________________________________________________ Fax
Phone ( )
__________________
City
_______________________________ State _______ Zip _______________
Telephone ( )
_________________
The
undersigned understand(s) that the above information is given for the
purpose of obtaining credit and authorizes the
investigation of this information.
I (We) certify that I am (we are) one of the above named principals
or officers, that the above statements
are true and complete, and that I (we) personally guarantee payment for
all goods ordered by the above company from Interstate Security, Inc.
Signed
__________________________________________
Date __________________________
Signed
__________________________________________
Date __________________________
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