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Business Credit Application Form
FROM: Kyle Curtis, Finance Manager | kyle@carolinabrick.com | 704.225.8117, Ext. 129
APPLICANT'S INFORMATION
Business Name
Date Business Opened
Address - Physical
Federal Identification #
Address Mailing
Business Type
Sole Proprietorship
Partnership
Limited Liability Company
Corporation
Office Phone
Contact Person
Contact Person’s Phone #
Contact Person’s Email
State of Incorporation / Organization
We are applying for credit with
Carolina Brick & Materials
Carolina Ready Mix
Our annual estimated purchases from Carolina Brick
Our annual estimated purchases from Carolina Ready Mix
Our requested Credit Limit from Carolina Brick
Our requested Credit Limit from Carolina Ready Mix
OWNERSHIP | OFFICER INFORMATION
1) Name
Title
Email
Street Address
City, State, & Zip
Mobile Telephone
2) Name
Title
Email
Street Address
City, State, & Zip
Mobile Telephone
3) Name
Title
Email
Street Address
City, State, & Zip
Mobile Telephone
BILLING INFORMATION | ACCOUNTS PAYABLE
AP Contact Person
Do you require a purchase order number?
Yes
No
AP Contact Person’s Phone #
Do you require monthly statements?
Yes
No
AP Contact Person’s Email
Do you have a designated email address for submission of invoices? If so, provide here.
PRIMARY BANK REFERENCE
Institution
Banker's Name
Street
Banker's Title
City, State & Zip
City, State & Zip
Bank's Telephone
Banker's Email
TRADE REFERENCES
1) Company
Contact Person
Street
Title
City, State & Zip
Contact Person Telephone
Company Telephone
Contact Person Fax
Company Fax
Contact Person Email
Account Opened
Credit Limit
Current Balance
2) Company
Contact Person
Street
Title
City, State & Zip
Contact Person Telephone
Company Telephone
Contact Person Fax
Company Fax
Contact Person Email
Account Opened
Credit Limit
Current Balance
3) Company
Contact Person
Street
Title
City, State & Zip
Contact Person Telephone
Company Telephone
Contact Person Fax
Company Fax
Contact Person Email
Account Opened
Credit Limit
Current Balance
DISCLOSURES AND SIGNATURE CONFIRMATION
Has the applicant or any of its principals ever filed for bankruptcy?
Yes
No
Has a tax lien or civil lawsuit been filed against the applicant or any of its principals within the last 6 years?
Yes
No
I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and condition of the credit to be extended to the company. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to Carolina Brick | Carolina Ready Mix for which credit is being applied and in order to verify the information contained herein.
Enter your full name in the field below. This will act as your digital signature.
Date
Questions?
Should you have any questions, you may reach Kyle Curtis at: 704.225.8117, Ext. 129. Email is kyle@carolinabrick.com.
Verification
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*
Example: 12
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