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Fax 919-781-4145
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Credit Application

 

Name/Address

First: Middile Initial: Last:
Email: Title:
Business Name: Tax ID:
Address:
Address Line 2:
City: State: Zip:
Phone:

Company Information

Type of Business: Annual Sales: In Business Since:
Legal Form of Business LLC  Corporation  Partnership  Proprietorship 
Name of Parent Company (if applicable):
Dun & Bradstreet Number:

Person Responsible for Business Transactions

Name: Title:
Address:
Address Line 2:
City: State: Zip:
Phone:

Bank References (1 of 1)

Institute Name: Checking Account #:
Address:
Address Line 2:
City: State: Zip:
Phone:

Bank References (2 of 2)

Institute Name: Savings Account #:
Address:
Address Line 2:
City: State: Zip:
Phone:

Trade References (1 of 3)

Company Name: Contact Name:
Address:
Address Line 2:
City: State: Zip:
Phone:
Account Open Since: Credit Limit: Current Balance:

Trade References (2 of 3)

Company Name: Contact Name:
Address:
Address Line 2:
City: State: Zip:
Phone:
Account Open Since: Credit Limit: Current Balance:

Trade References (3 of 3)

Company Name: Contact Name:
Address:
Address Line 2:
City: State: Zip:
Phone:
Account Open Since: Credit Limit: Current Balance:


By clicking the below submit button, I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit that may be extended. Furthermore, I hereby authorize the financial institutions, banks, and trade references listed in this credit application to release necessary information to JB Originals, LLC in order to verify the information contained herein. I hereby authorize JB Originals, LCC to make inquiries to the banking, savings, business, and/or trade references I have supplied.