EZ Credit Request / Increase Application - Rackcdn.com0b996d8a81b9cfa4a861-9c1613a5739e394df233fc02a87950de.r22.cf2.rackcdn.com/e...
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Shoprider Mobility Products, Inc 21184 South Figueroa Street Carson, CA 90745 Phone: (888) 896-8866 Fax: (888) 896-8185
Note:
By executing this application; the company, officers/owners, and/or guarantors agree and consent to allow Shoprider Mobility Products, Inc. to utilize the services of Equifax or any other credit reporting agency for the purpose of investigating the credit worthiness of the applicant and to report any failure to pay.
EZ Credit Request / Increase Application COMPANY DETAILS: Customer Number Name of Customer (Legal name)
Employer ID Number/Tax ID Number:
Trade Name
Date of Application
Mailing Address
City
State
Zip
Shipping Address
City
State
Zip
Main Phone Number
Fax Number
E-mail Address
Website Address
Contact person:
Contact Person’s Title:
Requested Credit Limit:
Requested Terms:
CREDIT REFERENCES: (Must supply at least three) Business/Trade name: Acct. Rep Acct No. 1.
Telephone No.
Fax No.
2. 3.
BANK REFERENCE: Name of Account Holder
Account Number
Bank Officer
____________________ Bank Name:
_________________ Phone Number
_________________ Fax Number:
____________________
_________________
_________________
Mailing Address (City, State, Zip) Customer authorizes Shoprider Mobility Products, Inc. to inquire and obtain information from bank, credit reference or any credit reporting agency with respect to applicant’s credit worthiness or financial condition. _________________________ Name of Customer _________________________ Signature
________________________ Date ________________________ Title
