SerVaas  INTERNET CREDIT APPLICATION TO BE PRINTED
Company's Full Name _________________________________________________________________________________
Address ______________________________________________________________ Phone _______________________________
City ___________________________ State ________________________ Zip Code __________________________

State of Incorporation _________________________ Date of Incorporation _________________________
Number of Employees _________________________ Total Annual Sales ____________________________
Has your company or its predecessor ever declared bankruptcy? ______________ When? ___________________________

Bank Reference:
Bank Name ______________________________________ Phone ____________________________________
Bank Address ___________________________________________________________________________________________
Account Officer ___________________________________ Checking Account No. ________________________________

Major Suppliers Granting Credit To Your Firm
Company
Address
Phone

1. ______________________________ _____________________________________ _______________
    _____________________________________  
2. ______________________________ _____________________________________ _______________
    _____________________________________  
3. ______________________________ _____________________________________ _______________
    _____________________________________  
4. ______________________________ _____________________________________ _______________
    _____________________________________  
5. ______________________________ _____________________________________ _______________
    _____________________________________  

The undersigned certifies that he/she is an officer of the above corporation (the "Applicant"), an authorized signatory of the Applicant, and that the information provided above is accurate.  The Applicant further agrees that it shall pay all invoices issued by SERVAAS LABORATORIES in accordance with the payment terms agreed to.

_________________________________________________ ____________________________________
Company
Date
   
_________________________________________________ ____________________________________
Signature
Title
   
_________________________________________________  
Printed Name
  


SerVaas Laboratories *Attn: Lisa Neace * 1200 Waterway Boulevard, Indianapolis, IN  46202 * 
Home