Business Credit Reports

Company Information

Company Name

Date

Address

City

State/Province

Zip/Postal Code

Country

Phone

Fax

Tax Identification #

DUNS #

Name of Owner, Principle, President

Type of Business

State Incorporated

If a division of subsidiary, Parent Co.

Buyer's Name

Buyer's Title

# of Years in Business

Product(s) Purchased

Source Industry Code (SIC)

Annual Usage (lbs./cwt, etc)

Contact Information

First Name

Last Name

Title

Phone

Accounts Payable Contact Information

First Name

Last Name

Title

Phone

Email to Send Invoices

Bank References

Bank Name

Account #

Contact

Address

City

State

Zip

Type of Account (Savings, Checking, Other)

Phone

Supplier Reference #1

Name

Address

City

State

Zip

Contact

Telephone #

Supplier Reference #2

Name

Address

City

State

Zip

Contact

Telephone #

Supplier Reference #3

Name

Address

City

State

Zip

Contact

Telephone #

Delivery Instructions

Ship To Address

Ship To City

Ship To State

Ship To Zip

Appointment Policy

Delivery Hours

Receiving Contact

Phone

Unload Procedure: Forklift (No touch/Driver help/Driver's job)

Unload Procedure: Pallet Jack (No touch/Driver help/Driver's job)

Unload Procedure: Hand (No touch/Driver help/Driver's job)

Truck Access Comment

Dock Height

Shipment Documentation Required

Send Documents to

Special Instructions #1

Special Instructions #2

Special Instructions #3

Request

Requested Amount

Comments (400 characters max)

Supporting Documentation

Please include a current financial statement with your application. If you have a filled out copy of the Uniform Sales & Use Tax Certificate - Multijurisdiction, please upload it as well.

Click the Browse / Choose Files button above to select the files you want to send. Then click the Upload button.
Please keep individual file sizes to 4MB or less.

Uploaded Documents

Terms

The undersigned hereby authorizes any bank, or other lender or grantor of credit, to provide St. Charles Trading, Inc. information regarding the character, reputation, financial responsibility and indebtedness of the undersigned as requested by SCT for the purpose of evaluating the commercial credit request of the undersigned, and hereby releases SCT and any lender or grantor of credit from any and all claims or causes of action that may arise of which he might have by reason of information furnished SCT by said bank or other lender or grantor of credit. Applicant agrees to pay interest at the rate of prime + two (2) points if account is 60 days past due. Applicant agrees to reimburse all legal and collection costs and fees if the account is more than 60 days past due.

I accept the above terms.

Please Sign Below

Using a touchpad or mouse, please sign in the area below. When finished signing, please click the Save Signature.

Submit the Request

By clicking 'Submit', I/We authorize St. Charles Trading, Inc. or its agent to obtain a credit report for the purpose of establishing, maintaining or enforcing a credit relationship. Upon approval of credit, I/We agree to pay our account according to the terms granted and I/We acknowledge that I/We have read and fully understand this application.

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