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         17319 Blaine Drive
Hagerstown, Maryland 21740
PHONE (301) 797-6500
FAX (301) 797-2510 fax
TOLL FREE 1-800-678-1919

Please print or type all information and return to the address shown above. ALL QUESTIONS MUST BE COMPLETED IN FULL
Please give addresses and telephone numbers for all references. Incomplete applications will be returned. You will be notified when credit has been approved. Allow time for references to reply by mail. We look forward to adding your name to our list of valued customers.


NAME OF COMPANY:
 
ADDRESS:TEL. No
FAX. No
 
EMAIL:
 
CITY: STATE: ZIP:
 
How long in business (in years) Current Net Worth $
 
Nature of business

OWNERSHIP: Corporation Partnership Proprietorship Other - Explain

Are you rated in D & B? Yes   No IF TAX EXEMPT. SEND CERTIFICATE
RATING:

BANK OPERATING ACCOUNT
with complete address and phone number(s)
 
Name:
 
Address
 
City: State: Zip:
 
Phone
 
Account No.
 
PRINCIPALS NAMES
 
Name:  Title:
Name:  Title:
Name:  Title:
Name:  Title:
Name:  Title:
 
TRADE REFERENCES - Complete addresses with street name, number and zip codes are essential - at least 3.
 
Trade Reference A
Name:
Address:
City: State: Zip:
Phone:       Fax:
 
Trade Reference B
Name:
Address:
City: State: Zip:
Phone:       Fax:
 
Trade Reference C
Name:
Address:
City: State: Zip:
Phone:       Fax:
 
Signed by:
Title:
 





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