Business Charge Application

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Nappanee

1524 E. Market St.
(574) 773-7523

Bremen

1245 W Plymouth St
(574) 248-6909

Elkhart

21826 SR 120
(574) 295-5806

Ligonier

1352 Lincolnway S.
(260) 894-3404

LaGrange

110 S Detroit St
(260) 585-8132

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Application Information

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

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone Number(Required)

Fax Number

Years at this address(Required)

Years in business(Required)

Accounts Payable Contact(Required)

Accounts Payable Email(Required)

Do you require a purchase order?(Required)

Yes

Type of Ownership(Required)

Corporation

Partnership

Sole Proprietorship

Federal ID #

Social Security #

Tax Exempt(Required)

Yes – Fill out Form ST-105.

Resale(Required)

Yes – Fill out the Certificate of Resale.

Type of Business(Required)

Ownership(Required)

Name of Officer and Position

Complete Address

Phone

Bank Name(Required)

Bank Address(Required)

Street Address Address Line 2 City State ZIP Code

Bank Officer or Department(Required)

Bank Phone(Required)

Business References(Required)

Business Name

Complete Address

Phone

Fax

Comments

List any Comments and/or Names of Persons Authorized to Charge to the Account: (will be treated as Open Account otherwise). Please notify us of any changes to this list.

I/we certify that all the information on this form is correct. I/we fully understand your credit terms and agree to the proper payment in consideration of extended credit. Furthermore, I/we approve of your obtaining information from the above references and a credit report on my company or if not a corporation, a report on me/us personally. If you update, renew, or extend my line of credit, you may request a new report without notice.

Date(Required)

Name(Required)

First Last

Title(Required)