Fax to EPG Finance / Credit Dept. (815) 673-6059

Billing Contact Information

Legal Name:
Phone:
Fax:
Email:

Address For Billing

Street Address:
City:
State/Province:
Zip/Postal:

Main Office Location

Street Address:
City:
State/Province:
Zip/Postal:

If Subsidiary

Name of Parent Company:
Street Address:
City:
State/Province:
Zip/Postal:

Legal Corporation (Include copy of Articles of Incorporation)

State/Province:
Entity:
Federal Tax ID#:

Limited Partnership Business

Sole Owner?
Yes
No

Started

Month: Year:

Owner, Partners, Officers Name(s)

Title:
Home Address:
City:
State/Province:
Zip/Postal:
Social Security Number:
Title:
Home Address:
City:
State/Province:
Zip/Postal:
Social Security Number:
Title:
Home Address:
City:
State/Province:
Zip/Postal:
Social Security Number:
Has any person named above declared or been involved in Bankruptcy?
Yes
No

Trade References

Name:
Address:
City:
State/Province:
Zip/Postal:
Contact:
Phone:
Fax:
Name:
Address:
City:
State/Province:
Zip/Postal:
Contact:
Phone:
Fax:

Bank References

Name:
Address:
City:
State/Province:
Zip/Postal:
Checking Account Number:
Loan Account Number:
Contact:
Phone:
Fax:
Name:
Address:
City:
State/Province:
Zip/Postal:
Checking Account Number:
Loan Account Number:
Contact:
Phone:
Fax:
Nature of Business:
Have you ever applied for an account with us before?
Yes
No
Do all orders REQUIRE a purchase order number?
Yes
No
Account balances over $15,000 must have current Financial Statements on file.
Financial Statements (balance sheet and income statement) furnished?
Yes
No
The above information is for the purpose of obtaining commercial credit and is warranted to be true, correct and complete. Creditor, its Agents, or any Credit Bureau employed by Creditor is hereby expressly authorized to investigate the references herein listed or other data obtained from Applicant or from any other person pertaining to Applicant's credit responsibility. Applicant also authorizes the above bank to release information regarding his checking account balances and loan relationships. Applicants signature attest to Applicants financial responsibility, ability and willingness to pay Creditors invoices in accordance with Creditors terms of Net 30 days. Applicant agrees to pay a service charge of 1 1/2% per month on the unpaid balance after 30 days. Furthermore, Applicant agrees to pay for all costs of collection, including reasonable attorney fees, court costs and collection agency fees.

Please fax to EPG Finance / Credit Dept. (815) 673-6059, or call (815) 672-3171.
Applicant's Name:
Authorized Signature & Title:
Date: