If you would like to apply for credit then put in an amount. If you will be paying with credit card then just fill out the business information.

The undersigned desires credit in the amount of:   Application Date:

Business or Corporate Name:

Business Street Address:

City: State: Alabama Alaska Arkansas Arizona California Colorado Connecticut Deleware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachussetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming Other    Zip Code: Country: 

Business Telephone #: - Fax #: -

E-Mail Address: (if no e-mail, enter "n/a")

Billing Address: (if different than above)

Street or P.O. Box    City:

State:    Zip / Postal Code: Country:

President or Manager or Owner: Year Business Established:

Type of Ownership: Sole Proprietor   Partnership Corporation

Resale Permit #:

Principal Place of Business is: Owned   Rented

Buyer Contact Name:

Accounts Payable Contact Person:

Owners (if applicant is a sole proprietor or partnership)  Officers (if corporation):

Name: Title:

Social Security #: Home Telephone #: -

Home Address: City:

State: Zip / Postal Code:

Country or Province (if outside U.S.):

Bank or Savings and Loan Association:

Name: Branch Address:

City: State:

Zip / Postal Code: Country or Province (if outside the U.S.):

Phone #: -   Account #:

Trade References (List at least three for Credit Reference)

Name: Address:

City: State: Zip / Postal Code:

Country or Province (if outside the U.S.):

Phone #: - Account #:

Name: Address:

City: State: Zip / Postal Code:

Country or Province (if outside the U.S.):

Phone #: - Account #:

Name: Address:

City: State: Zip / Postal Code:

Country or Province (if outside the U.S.):

Phone #: - Account #:

Has Applicant or any of it's Owners, Principals, Partners, Officers, or Directors ever filed a voluntary petition in bankruptcy, been a judged bankrupt, or made an assignment for the benefit of creditors?

No   Yes

1. Do you require a purchase order or requisition number on each invoice?
No Yes

Name of applicant submitting form: Date:

Submission of the following form authorizes release of all credit information requested by Sports Prescriptions, Inc.

(All information submitted on this form is entirely confidential).