Business Credit Application Form

• FROM: Kyle Curtis, Finance Manager | kyle@carolinabrick.com | 704.225.8117, Ext. 129

APPLICANT'S INFORMATION

• Business Name
• Date Business Opened
• Address - Physical
• Federal Identification #
• Address Mailing
• Business Type
  Sole ProprietorshipPartnershipLimited Liability CompanyCorporation
• Office Phone
• Contact Person
• Contact Person’s Phone #
• Contact Person’s Email
• State of Incorporation / Organization
• We are applying for credit with
  Carolina Brick & MaterialsCarolina Ready Mix
• Our annual estimated purchases from Carolina Brick
• Our annual estimated purchases from Carolina Ready Mix
• Our requested Credit Limit from Carolina Brick
• Our requested Credit Limit from Carolina Ready Mix

OWNERSHIP | OFFICER INFORMATION

• 1) Name
• Title
• Email
• Street Address
• City, State, & Zip
• Mobile Telephone
•  
• 2) Name
• Title
• Email
• Street Address
• City, State, & Zip
• Mobile Telephone
•  
• 3) Name
• Title
• Email
• Street Address
• City, State, & Zip
• Mobile Telephone

BILLING INFORMATION | ACCOUNTS PAYABLE

• AP Contact Person
• Do you require a purchase order number?
  YesNo
• AP Contact Person’s Phone #
• Do you require monthly statements?
  YesNo
• AP Contact Person’s Email
• Do you have a designated email address for submission of invoices? If so, provide here.

PRIMARY BANK REFERENCE

• Institution
• Banker's Name
• Street
• Banker's Title
• City, State & Zip
• Banker's Telephone
• Bank's Telephone
• Banker's Email

TRADE REFERENCES

• 1) Company
• Contact Person
• Street
• Title
• City, State & Zip
• Contact Person Telephone
• Company Telephone
• Contact Person Fax
• Company Fax
• Contact Person Email
• Account Opened
• Credit Limit
• Current Balance
•  
• 2) Company
• Contact Person
• Street
• Title
• City, State & Zip
• Contact Person Telephone
• Company Telephone
• Contact Person Fax
• Company Fax
• Contact Person Email
• Account Opened
• Credit Limit
• Current Balance
•  
• 3) Company
• Contact Person
• Street
• Title
• City, State & Zip
• Contact Person Telephone
• Company Telephone
• Contact Person Fax
• Company Fax
• Contact Person Email
• Account Opened
• Credit Limit
• Current Balance

DISCLOSURES AND SIGNATURE CONFIRMATION

• Has the applicant or any of its principals ever filed for bankruptcy?
  YesNo
• Has a tax lien or civil lawsuit been filed against the applicant or any of its principals within the last 6 years?
  YesNo
• I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and condition of the credit to be extended to the company. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to Carolina Brick | Carolina Ready Mix for which credit is being applied and in order to verify the information contained herein.
• Enter your full name in the field below. This will act as your digital signature.
• Date
• Questions? Should you have any questions, you may reach Kyle Curtis at: 704.225.8117, Ext. 129. Email is kyle@carolinabrick.com.

 

Verification

• Please enter any two digits *Example: 12
• This box is for spam protection - please leave it blank: