Welcome, Guest | Login
Call Us: 800-597-3022 MON-FRI 7AM-4PM PT

Credit App

Business Name__________________________________Date______________
Address______________________City__________State_________Zip_____
Owner/Manager_______________________________Tel.No.______________
How long in business__________D & B Rated_______________________
Fax_______________Email_____________
Credit Card Number For File:_______________________Exp Date_____
Credit Card Holders Name:_______________________________________
Bank Name_______________Address________________________________
Bank Phone____________________Accounts Payable Contact__________


Trade References:
Name_______________________________Phone_______________________
Name_______________________________Phone_______________________
Name_______________________________Phone_______________________
Name_______________________________Phone_______________________

Credit line requested $_________________________________
Agree to Net 30 Day Terms yes__ no__
___________________________________________________
___________________________________________________
___________________________________________________


The undersigned authorizes inquiry as to credit
information. We further acknowledge that credit privileges, if
granted, may be withdrawn at any time. The Undersigned authorizes Credit Card to Be billed with a 3% processing fee added to bill if not paid within net terms.

Authorized Signature:_________________________________

Centerlen Services
2801 Junipero Ave Suite 204
Signal Hill, CA 90755
Fax 562-424-5202