IJN Distribution, INC - Credit Application Form

Please provide the following information: *Denotes required field
*Company Name:
*Mailing Address:
*City:
*State:
*Zip Code:
*Country:
*Telephone:
Fax:
*E-Mail:
Website Address:
ADDRESS FOR INVOICES (if different from above)
Address:
City:
State:
Zip Code:
ATTENTION LINES FOR INVOICES
Statement:
Freight Invoice:
Manufacturing Invoice:
Storage Invoice:
*Accounts Payable Contact:
*Accounts Payable Telephone:
*Accounts Payable E-Mail:
*TIN (Federal Tax ID) or SS#:
D&B D-U-N-S #:
Date business established:
Number of employees:
TRADE REFERENCES
*Company:
*Contact:
*Fax or E-Mail:
*Company:
*Contact:
*Fax or E-Mail:
*Company:
*Contact:
*Fax or E-Mail:
Company:
Contact:
Fax or E-Mail:
BANK REFERENCES
*Bank:
*Contact:
*Bank Telephone:
*Bank Address:
Address (Cont.):
*Type of Account:
*Account Number:
APPLICATION AUTHORIZATION
*Please enter your date of birth to initiate authorization of this application
*Title:
*Today's Date:

IJN Distribution Inc. Copyright © 2006 All rights reserved.