Credit RequestLet Allied help you get the job completed

Company Information
Dun & Bradstreet #:
SS# / Tax ID #:
Company Name:
Contact Name:
Email:
Address:
City:
State:
Zipcode:
Phone:
Fax:
Billing Information
 
Same as above
Billing Name:
AP Name:
Phone:
Fax:
Address:
City:
State:
Zipcode:
Type of Business:
Additional Information
Number of Years in Business Under Current Name:
Business previously held under any other names?:
Has the current owner ever filed for bankruptcy protection before?:
Number of Employees:
Annual Sales Volume:
Number of Years at Current Location:
Tax Exempt?:
Payment Personally Guaranteed?:
Ownership
Name of Owner(1):
Address(1):
City(1):
State(1):
Zipcode(1):
Phone(1):
Fax(1):
Name of Owner(2):
Address(2):
City(2):
State(2):
Zipcode(2):
Phone(2):
Fax(2):
Trade Reference
Company Name(1):
Contact(1):
Email(1):
Address(1):
City(1):
State(1):
Zipcode(1):
Phone(1):
Fax(1):
Company Name(2):
Contact(2):
Email(2):
Address(2):
City(2):
State(2):
Zipcode(2):
Phone(2):
Fax(2):
Company Name(3):
Contact(3):
Email(3):
Address(3):
City(3):
State(3):
Zipcode(3):
Phone(3):
Fax(3):
Bank Reference
Bank Name(1):
Contact(1):
Email(1):
Address(1):
City(1):
State(1):
Zipcode(1):
Phone(1):
Fax(1):
Bank Name(2):
Contact(2):
Email(2):
Address(2):
City(2):
State(2):
Zipcode(2):
Phone(2):
Fax(2):
Applicants Statement
I certify that statements made herein are true and accurate to the best of my knowledge.
I authorize investigation of all statements contained in this application for credit as may be necessary in arriving at a decision.
I hereby indemnify the above company from any liability resulting from this credit survey.

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