Credit Card Intake Form Company Name Sole Proprietor? Yes No Partnership? Yes No Corporation? Yes No Owner First Last President First Last Mailing Street Address City State ZIP Company Street Address City State ZIP Email PhoneCellContractor's License # Contractor's License Exp MM slash DD slash YYYY Contractor's State Federal ID # Bonding Agent First Last PhoneStreet Address City State ZIP Person Responsible for Accounts Payable First Last Credit References (3 References Minimum)Credit Reference 1 Name First Last Credit Reference 1 Email Credit Reference 1 PhoneCredit Reference 1 Address Credit Reference 2 Name First Last Credit Reference 2 Email Credit Reference 2 PhoneCredit Reference 2 Address Credit Reference 3 Name First Last Credit Reference 3 Email Credit Reference 3 PhoneCredit Reference 3 Address Credit Reference 4 Name First Last Credit Reference 4 Email Credit Reference 4 PhoneBanking InformationName First Last Bank Street Address City State Banking Account # CertificationThe Applicant certifies the following: (1) the information I provided is true and correct and has been submitted to obtain commercial credit; (2) I am authorized to execute applications and other documents required to establish commercial credit accounts on behalf of Applicant; (3) Ozark Rebar, LLC is hereby authorized to investigate and verify any information provided and inquire of references or others as to credit worthiness; (4) Ozark Rebar, LLC may answer questions from others about its credit experience with the Applicant; and (5) I have read, understood, and agreed to all of the TERMS AND CONDITIONS and agree to notify Ozark Rebar, LLC, in writing via certified mail, of any material change in name, ownership, location, corporate status, or financial condition within five (5) days. If applicant is a partnership or sole proprietorship, then I authorize Ozark Rebar, LLC to obtain and use consumer reports on the Applicant or its principals for the sole purpose of evaluating current or ongoing credit worthiness.Contact First Last PhoneSignature First Last PhoneTitle Name First Last Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. 6547587612
