Credit Application

Download this PDF,
fill it out and fax it to us at (502) 560-1455,
or fill out the form below.
Name *
Name
Company Information
Phone Number *
Phone Number
Fax Number
Fax Number
If Different From Billing Address
Sales Tax Exemption *
Tax Exemption Type
If Tax Exempt
Trade References
Contact Name (1) *
Contact Name (1)
Contact for Company (1)
Phone Number (1) *
Phone Number (1)
Phone Number for Company (1)
Address for Company (1)
Contact Name (2) *
Contact Name (2)
Contact for Company (2)
Phone Number (2) *
Phone Number (2)
Phone Number for Company (2)
Address for Company (2)
Contact Name (3) *
Contact Name (3)
Contact for Company (3)
Phone Number (3) *
Phone Number (3)
Phone Number for Company (3)
Address for Company (3)
Bank
Bank Contact *
Bank Contact
Bank Phone Number *
Bank Phone Number
Names and Titles
Of Officers / Partners / or Principles if Company is Corporation, Partnership, or LLC
Name
Name
Name
Name
Name
Name
Agreement
Consent *
All information provided is true to the best of our knowledge. I (we) consent to Derby City Litho contacting the bank and trade references listed above, and credit reporting agencies that they deem appropriate to inquire about our credit. I (we) agree to pay court costs, reasonable attorney’s fees, and interest incurred in the collection of any unpaid balances. I (we) agree that payment terms on all invoices are net 30, unless otherwise states in writing on the invoice or other contract documents, and to pay 1.5% of the balance late charge each month for any invoice not paid within 30 days of its due date. I (we) authorize the listed bank and trade references listed to release information to derby city litho regarding their credit/financial experience with us.
Your Name *
Your Name
Date *
Date
Today's Date