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Application for Credit

For questions regarding this application CALL 610-859-3574. If printing, FAX back to 610-497-6498.

Full Company Name: Years in Business:
Street Address: City: State: Zip:
Billing Address: City: State: Zip:
Telephone: Fax: A/P Contact Name:
 
Are you EDI capable? Yes No If yes: 850 P.O. 810 Invoice 820 Remittance
 
Business Structure
Corporation Proprietorship Partnership Other:
If Incorporated, State of incorporation: Year of Incorporation:
Subsidiary: Yes No Division: Yes No Duns #:
If yes, Name & Address of Parent Company: Tax ID #:
 
Has business / officer ever filed for bankruptcy? Yes No
If yes, when: Chapter: 7 Chapter: 11 Chapter: 13
 
Name of Principal(s) Title
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2.
3.
 
Bank and / or Lender References (list all secured parties)
Name, Address, Contact Name Phone Account #
1.
2.
3.
 
Trade References
Name & Address Phone Fax
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4.
 
I / We agree to make all payments within our 30 day terms with Pennsylvania Machine Works, Inc. If it becomes necessary to file a lien, suit or engage a collection agency or attorney, I / We agree to bear all expenses incurred (whether or not suit is filed), including but not limited to attorney fees, court costs, and a 1-1/2% interest charge per month on all disputes goverened by the laws of Pennsylvania.
 
I hereby release any and all credit or financial information to Pennsylvania Machine Works, Inc.; by providing my email address, or signing I am accepting your conditions of sales and testifying the above information is true to the best of my knowledge.
 
  Email address (required): Name: Title: Date: