LodgeMart.com	Business Credit Application
LodgeMart.com is a Division Of RSA Distributors, Inc. Tel: (631) 243-0123 (631)243-0140 Email: sales@lodgemart.com

Please Print & Complete This Credit Application & Fax to (631) 243-0140

Name/Address

Last: First: Middle Initial:	Title
Name of Business:	Tax I.D. Number
Address:
City: State: ZIP: Phone:

Company Information

Type of Business: In Business Since:

Legal Form Under Which Business Operates:

Corporation ð Partnership ð Proprietorship ð

If Division/Subsidiary, Name of Parent Company: In Business Since:

Name of Company Principal Responsible for Business Transactions: Title:

Address: City: State: ZIP: Phone:

Name of Company Principal Responsible for Business Transactions: Title:

Address: City: State: ZIP: Phone:

Bank References

Institution Name:	Institution Name:	Institution Name:
Checking Account #:	Savings Account #:	Home Equity Loan:	Loan Balance:
Address:	Address:	Address:
Phone:	Phone:	Phone:

Trade References

Company Name:	Company Name:	Company Name:
Contact Name:	Contact Name:	Contact Name:
Address:	Address:	Address:
Phone:	Phone:	Phone:
Account Opened Since:	Account Opened Since:	Account Opened Since:
Credit Limit:	Credit Limit:	Credit Limit:
Current Balance:	Current Balance:	Current Balance:

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein.

__________________________________________ ______________________________________

Signature Date