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Application for Credit
Merchant's Delivery Inc.
BY:
Company Name:______________________________________
Company Address:______________________________________
City:_________________________State:______________ Zip:_______________
Phone:_____________________ Fax:____________________
Years at this address:_____________________

To:
Merchants Delivery Inc.
223 W. Lincoln
Madison Heights, MI 48071
Patsy Christopher
Credit Manager

Credit Terms: NET 15

The following information must be provided. It will be held in the strictest of confidence.

Ownership: ___Corperation
___Partnership
___Check here if incorperated in last 12 months.
___ Individual
Name of Principal(s):
1.________________________
2.________________________
3.________________________
Complete addresses:
___________________________________
___________________________________
___________________________________
Phone:
________________
________________
________________
Fax:
_______________
_______________
_______________

Bank:___________________ Bank Address:__________________
Bank Officer/Department:__________________ Phone:________________

References:
business Name: Complete Address: Phone:
1._______________________ _________________________ _________________________
2._______________________ _________________________ _________________________
3._______________________ _________________________ _________________________

____Check here if cash sales are okay until credit is approved.

We certify that all information on this form is correct. We fully understand your credit terms
and agree to the proper payment in consideration of extended credit.
Date:____________ Signed:__________________________
Title:____________________________

Please do not write below this space

References checked by:_________________ Date:____________________
results:____________________________________
___Credit Approved by:_____________________ ___Credit refused by:_____________________