PARKEROCEANIC CREDIT APPLICATION
Vendor Information
Vendor Name:
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Estimated Equipment Cost:
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Vendor Contact:
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Brief Equipment Description:
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Vendor Phone:
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Vendor Fax:
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Customer Information
Full Legal Company Name
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Billing Address
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Business Street Address (if different from Billing Add.)
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Bank Use:
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City, State, Zip
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Phone:
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Type of Business
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Years In Business
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Annual Sales
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Email Address
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Business Owner’s Name
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Title
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Years As Owner
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# of Employees
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Date of Birth
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Legal Structure: (circle one)
LLC Non-Profit Sole Proprietor
Partnership Corporation
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State of Incorporation
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State Organization Number
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Principal I Name
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Principal I Address
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City, State, Zip
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Principal I E-Mail Address
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Principal I Social Security Number
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Principal I Ownership %
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Principal II Name
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Principal II Address
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City, State, Zip
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Principal II E-Mail Address
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Principal II Social Security Number
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Principal II Ownership %
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Bank & Trade References
Bank
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Phone #
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Account #
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Contact
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Bank
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Phone #
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Account #
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Contact
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Company Name
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Phone #
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Account #
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Contact
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Company Name
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Phone #
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Account #
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Contact
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Your Signature
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The undersigned individual(s), recognizing that his or her individual credit history may be a factor in the evaluation of the credit of the applicant, hereby consents to and authorizes the above named business credit provider and any assignee, lender or funding service that may be utilized to obtain and use a consumer credit report on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process and waives any right or claim they would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent. By signing below, I also wish to continue to receive updates from PARKEROCEANIC regarding our account. Information should be sent to the fax and/or email address given for the account. If for any reason your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please write to PARKEROCEANIC, PO BOX 182, HOLT, CA 95234 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial of credit within 30 days of receiving your request for the statement.
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Principal I Signature Date Principal II Signature Date
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Please complete and EMAIL to David Parker
Phone: 916-289-7797 ¨ ¨ Email: dp@parkeroceanic.com
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