Bill To:
Name:
Address:
City:
State:
Telephone:
Fax:
Email:
Zip:
Business Structure (please check one):
Corporation:
Partnership:
Single Owner:
Federal Id #:
How Many Years in Business:
Have you ever filed for Bankruptcy:
Yes
No
Company Name
State of Incoporation:
Partner Name:
Name of Individual Owner:
Home Phone:
General Information
Name of Buyer:
Resale #:
(California Only)
Credit Rating in Dun & Bradstreet
Listed Under:
D & B #:
References: (List all information carefully.)
1. Bank:
Name Address City/State/Zip Phone/Fax #’s
Trade References:
2.:
3.:
4.:
5.:
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