Business Credit Reports

Company Information

Company Name

Address

City

State/Province

Zip/Postal Code

Country

Legal Form (Corporation, Partnership, or Proprietorship)

Subsidiary of

Division of

Type of Business

# of Years in Business

Net Worth

DUNS #

Sales per Year

President/CEO

VP/Finance

Treasurer/Controller

A/P Manager

Billing and Shipping Information

Billing Address

Billing City

Billing State

Billing Zip

Main Telephone

Main Fax

A/P Fax

A/P Email

Shipping Address

Shipping City

Shipping State

Shipping Zip

Contact Information

First Name

Last Name

Title

Phone

Bank Reference

Bank

Account #

Phone

Contact

Address

City

State

Zip

Credit Reference #1

Company

Contact

Phone

Fax

Credit Reference #2

Company

Contact

Phone

Fax

Credit Reference #3

Company

Contact

Phone

Fax

Request

Requested Amount

Comments (400 characters max)

Supporting Documentation

Please provide copies of all applicable tax exemption certificates.

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By clicking 'Submit', I/We authorize Kelser Corporation 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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