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Company Information
Company Name _______________________________________________________________________________
Other Trade Names ____________________________________________________________________________
Address____________________________________City________________________State________Zip________
Billing Address_______________________________City________________________State________Zip________
Contact:__________________________________________ Billing Contact _______________________________
Type of Business in the State of________ Corporation _________ Partnership __________ Sole Proprietor _________
Phone____________________________ FAX______________________ Email____________________________
Bank Information
Bank Name____________________________________ Account #(s)____________________________________
Address____________________________________City________________________State________Zip________
Contact Name_______________________________________ Phone ____________________________________
Trade References - Please Provide Three (3)
Company ___________________Contact _____________________Phone ______________________
Company ___________________Contact _____________________Phone ______________________
Company ___________________Contact _____________________Phone ______________________
Officer(s)/Owner(s)
Client submits this application for LABORCHEX’s use in determination of an appropriate line of credit. Client understands and agrees that under the provisions of the Fair Credit Reporting Act (FCRA), LABORCHEX may request a business credit report or consumer report for the purpose of verifying statements made above. Your signature below authorizes LABORCHEX to obtain this report(s). A copy of this report(s)--if obtained--will be made available to you upon your request.
Authorized Signature
Title___________________________________________________ Date____________________, 20__