CUSTOMER APPLICATION FOR CREDIT - Port Austin Level & Tool Manufacturing Company
P.O. Box 365 - 130 Arthur Street - Port Austin, MI 48467 - Phone:989.738.5291 - 800.835.1798 - FAX 989.738.6151

FIRM NAME: _____________________________________________________________________________________

MAILING ADDRESS: _______________________________________________________________________________

SHIPPING ADDRESS: ______________________________________________________________________________

TELEPHONE: ________________________ FAX: _________________________ E-MAIL: _______________________

CORPORATION: _______ PARTNERSHIP: _______ PROPRIETORSHIP: ________ RESALE #:____________________

OWNER OR EXECUTIVE: __________________________________ BUYER: __________________________________

FINANCIAL OFFICER OR CREDIT MANAGER:___________________________________________________________

BANK REFERENCE:

BANK: ________________________________________ BRANCH: _________________________________________

ACCOUNT NO: _________________________________ CONTACT:________________________________________

COMPLETE ADDRESS: ____________________________________________________________________________

PHONE: _______________________________________ FAX: ____________________________________________

TRADE REFERENCES:

1. NAME:_______________________________________________________________________________________

ADDRESS: ___________________________________________ CITY: _____________________________________

STATE: ______________________ ZIP: _____________ CONTACT: _______________________________________

PHONE: _______________________________________ FAX: ____________________________________________

2. NAME:_______________________________________________________________________________________

ADDRESS: ___________________________________________ CITY: _____________________________________

STATE: ______________________ ZIP: _____________ CONTACT: _______________________________________

PHONE: _______________________________________ FAX: ____________________________________________

3. NAME:_______________________________________________________________________________________

ADDRESS: ___________________________________________ CITY: _____________________________________

STATE: ______________________ ZIP: _____________ CONTACT:_______________________________________

PHONE: _______________________________________ FAX: ____________________________________________

I have read and hereby accept the terms of this agreement:

Signature: _______________________________________________________________________________________