14927 South Heritagecrest Way
Bluffdale, Utah 84065
OFFICE: 801-746-3811 FAX: 801-746-3812
www.flotechinc.biz
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CREDIT APPLICATION
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COMPANY NAME
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MAILING ADDRESS
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STATE
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ZIP
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TELEPHONE
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FAX
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EMAIL
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COMPANY DATA
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TYPE OF CORP,PARTNERSHIP, OR PROPREITORSHIP (IF INC. PROVIDE STATE)
BUSINESS
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TAX STATUS EXEMPT OR NON-EXEMPT (IF TAX EXEMPT A RESALE OR EXEMPTION CERTIFICATE REQUIRED) TC-721
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PRESIDENT, OWNER, OR PARTNER
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TREASURER OR PARTNER
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AUTHORIZED BUYER(S)
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PURCHASE ORDER REQUIRED?
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ACCOUNTS PAYABLE CONTACT NAME
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BANK REFERENCES
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BANK NAME
CONTACT
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ADDRESS
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ACCOUNT NUMBERS
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FAX
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BANK NAME
CONTACT
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ADDRESS
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ACCOUNT NUMBERS
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PHONE
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CREDIT REFERENCES
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TRADE REFERENCE
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ADDRESS/CITY/STATE/ZIP
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PHONE
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TRADE REFERENCE
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ADDRESS/CITY/STATE/ZIP
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PHONE
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FAX
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ADDRESS/CITY/STATE/ZIP
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PHONE
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FAX
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SIGNATURES
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Authorized Signature: Title: Date:
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