Credit Application

Credit Application Please return via fax at (614) 882-7312
Mindy Bendure - Financial Manager
Net 30 Days - Credit Terms

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Company Name Area Code Phone

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Address Years At Address

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City, State Zip Code Federal Tax ID Number

The following information must be provided and will be held strictly confidential.

____Corporation ____Incorporated in the past 12 months ____Partnership ____Individual

Name(s) of Principal(s) Complete Address Phone

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Bank Address Phone

REFERENCES
Business Name Phone/Fax Address

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We certify that all the information on this form is correct. We fully understand your credit terms and agree to the proper payment in consideration of extended credit.

_____________________________                       PSS INC. ONLY
Signed                                                              Reference Check__________ Date_________
_____________________________                      Reference Results______________________
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_____________________________                       Credit Approved_______Denied__________
Print Name