P.O. Box 243, Laredo, TX 78042 www.farias.com

Tel: (956) 723-1583 Fax: (956) 727-7627

 

Company Name: ________________________________________________________

Business Address: ________________________________________________________

 

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Mailing Address: ________________________________________________________

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Accounts Payable Contact: __________________________ Email Address: _________________

Parent Company (if subsidiary): ________________________________________________________

Telephone: _________________________ Fax: __________________________

What type of business: Sole Proprietor: Partnership: Corporation:

State of Incorporation: ________________________________________________________

Name & Address of Owners/Principles: _____________________________________________________

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Fed ID or Social Security Number: _________________________________________________________

Year Business Started: _____________ Years At Present Location: ___________

Credit Amount Requested: _________________

BANK REFERENCES:

Bank Name: ____________________________________________________________________

Address: ____________________________________________________________________

Officer: _______________________________ Telephone: __________________________

Account Number: _________________________ Checking: Savings: Money Market:

Bank Name: ____________________________________________________________________

Address: ____________________________________________________________________

Officer: _______________________________ Telephone: __________________________

Account Number: _________________________ Checking: Savings: Money Market:

TRADE REFERENCES:

First Firm Name: ___________________________________ Telephone: ______________________

City/State: _____________________________ Contact Name: _______________________

Second Firm Name: ___________________________________ Telephone: ______________________

City/State: _____________________________ Contact Name: _______________________

Third Firm Name: ___________________________________ Telephone: ______________________

City/State: _____________________________ Contact Name: _______________________

For the purposes of obtaining services from Farias & Farias, Inc., the above statement in writing is made, intending that you should rely on the same as correct. Should our account become delinquent, we agree to pay any late charges and if collection is turned over to a third party, we agree to pay all fees incurred by Farias & Farias, Inc., including attorney’s fees and court costs. Applicant by signing attests to financial responsibility and acknowledges reading and agreeing to all terms of Farias & Farias, Inc. Terms of Agreement. The owner or corporate officer must sign this document. Signature below authorizes release of bank and trade information to Farias & Farias, Inc.

Signature: _______________________________________ Title: ____________________________________________

Print Name: ______________________________________________ Date: ___________________________________