CUSTOMER/CREDIT APPLICATION CONTACT INFORMATION

CUSTOMER/CREDIT APPLICATION
CONTACT INFORMATION
Date:
Business Name:
Contact/Buyer:
E-Mail:
Phone:(
Fax:(
)
)
Owner:
Phone: (
)
Home Address:
Shipping Address:
Mailing Address:
Date Opened:
Type of Business?
Corporation
Partnership
Proprietorship
Mail
Fax
E-Mail
C.O.D.
Credit Card
Credit
Receive Invocies &
Statements by?
What type of Account
are you Requesting?
REFERENCES (If Applying for Credit, Please Fill Out Reference Section Below)
Bank:
Officer:
Address:
Phone:(
Fax:(
)
)
Business:
Address:
Phone:(
Fax:(
)
)
Business:
Address:
Phone:(
Fax:(
)
)
Yes
ADDITIONAL INFORMATION
Do orders from your company rquire a P.O. number?
Do you request items NOT IN STOCK to be placed on back order?*
*C.O.D. and Credit Card customers DO NOT Receive Backorders
I
P.O. Box 11608
out of state 800.354.9350
email sales@breederssupply.com
Lexington, KY 40576
in KY 800.432.9342
www.breederssupply.com
No