Business Credit Reports

Company Information

Company Name

Address

City

State/Province

Zip/Postal Code

Country

Mailing Address

Phone

Fax

Legal Form (Corporation, Partnership, or Proprietorship)

Date Business Commenced

Years at Current Address

Tax Exempt? (Yes/No)

Tax Exempt #

Contact Information

First Name

Last Name

Title

Phone

Purchasing Name

Phone Number

Email Address

Accounts Payable Contact Information

First Name

Last Name

Title

Phone

Fax

Billing Reference

Email or Fax

Email Address

Fax #

PO Required?

Bank Information

Bank Name

Account #

Primary Address

Point of Contact

Type of Account (Savings/Checking/Other)

Phone

Fax

Credit Reference #1

Company Name

Address

City

State

Zip

Phone

Fax

Terms

Other

Credit Reference #2

Company Name

Address

City

State

Zip

Phone

Fax

Terms

Other

Credit Reference #3

Company Name

Address

City

State

Zip

Phone

Fax

Terms

Other

Requested Amount

Requested Amount ($25,000/$50,000/$100,000/$150,000/$200,000/Other)

If Other, please enter amount

Greenrise's Sales Representative (Please enter a full name)

Supporting Documentation

If you are Tax Exempt, please provide your exemption certificate

Click the Browse / Choose Files button above to select the files you want to send. Then click the Upload button.
Please keep individual file sizes to 4MB or less.

Uploaded Documents

Terms

Terms & Conditions

I accept the above terms.

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Submit the Request

By clicking 'Submit', I/We authorize Greenrise Technologies LLC or its agent to obtain a credit report for the purpose of establishing, maintaining or enforcing a credit relationship. Upon approval of credit, I/We agree to pay our account according to the terms granted and I/We acknowledge that I/We have read and fully understand this application.

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