1) BUSINESS CONTACT INFORMATION (REQUIRED FOR ALL NEW CUSTOMERS)

Company Name

Billing Address

City

State

Zip

Check if billing and shipping addresses are the same

Shipping Address

City

State

Zip

Phone

DEA #

Fax

State License

Email

Owner/Officer

Position

Authorized Buyer

Phone

Accounts Payable Contact

Phone

Monthly Statements

Statement Delivery


    

THE ABOVE INFORMATION IS FOR THE PURPOSE OF OBTAINING COMMERCIAL CREDIT AND IS WARRANTED TO BE TRUE AND CORRECT. IF KEYSOURCE OR ITS AGENTS CONSIDER A CREDIT REPORT RELEVANT AND NECESSARY TO ASSISTING THIS REQUEST FOR CREDIT, THE UNDERSIGNED AUTHORIZES KEYSOURCE OR ITS AGENTS TO OBTAIN, FROM A CREDIT REPORTING AGENCY, A CREDIT REPORT CONTAINING PERSONAL CREDIT INFORMATION ABOUT THE APPLICANT. THE UNDERSIGNED AUTHORIZES KEYSOURCE OR ITS AGENTS TO INVESTIGATE THE REFERENCES LISTED PERTAINING TO THE APPLICANT’S CREDIT AND FINANCIAL RESPONSIBILITY, AND PERSONALLY GUARANTEES PAYMENT. A COPY OF THIS APPLICATION SHALL BE DEEMED AS AN ORIGINAL.





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