Glass Graphics Credit Application

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Please be sure to fill in the application completely to ensure the fastest responce.

- Account Application Form - * These are required fields

Part I: Business Information

Business Name: *
ASI # *

Date:

Physical Address:

(Street)

(City)

(State)

(Zip)

Type of Business: Corporation LLC Partnership Proprietorship

Bank of Record:

(Name)

(Contact)

(Account #)

Part II: Contact & Mailing Information

(1) Main Contact	(2) Accounts Payable Contact
Name Position	Name Position
Mailing Address	Mailing Address
City State Zip	City State Zip
Phone * Fax	Phone Fax
E-mail *	E-mail

Part III: Trade References (5 required)

1.Company	Account #	Fax
2.Company	Account #	Fax
3.Company	Account #	Fax
4.Company	Account #	Fax
5.Company	Account #	Fax

Part IV: Acknowledgement

The undersigned certifies that all information in this registration form is complete, factual, and correct. Glass Graphics will rely on the accuracy of this information for the purpose of establishing your account and determining any credit terms that may be extended. In signing this registration form the signatory hereby authorizes Glass Graphics to contact any parties listed herein to verify the information contained in this form.

Authorized Signature: *
Title of Signatory:
Date:

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Glass Graphics
Specializing in Crystal, Wood, Marble & Nickel Plated Products.