This form is to be printed out & either mailed or faxed to:
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Sullivans USA, Inc. 4341 Middaugh Ave. Downers Grove, IL 60515 Phone: 1-630-435-1530 Fax: 1-630-435-1532 Return To: Credit Manager Date ___/___/___ APPLICATION FOR CREDIT BILLING ADDRESS: (please print) Company Name: ________________________________________________________________________ Owner(s) Name: ________________________________________________________________________ Buyers name if differnet ________________________________________________________________________ Address: ________________________________________________________________________ City, State, Zipcode: ________________________________________________________________________ Daytime Phone: ____________________________________ FAX# _____________________________ SHIPPING ADDRESS: Name: ________________________________________________________________________ Address: ________________________________________________________________________ City, State, Zipcode: ________________________________________________________________________ Daytime Phone: ________________________________________________________________________ Special Instructions: ________________________________________________________________________ TYPE OF BUSINESS: Sole Owner: ____ CORPORATION: ____ PARTNERSHIP: ____ Date Established under present ownership: ________________________________________________________________________ Rated in Dun and Bradstreet? _________________________________ Duns#________________________________ Resale Tax ID# ________________________________________________________________________ (Please attach copy of your resale certificate) BANK REFERENCES: Bank Name: ________________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip ________________________________________________________________________ Checking Account # ________________________________________________________________________ TRADE REFERENCES: 1. Name: ._________________________________________ACCT#___________________ Address: .____________________________________________________________ City _________________State:___________________Zip:________ Phone # ._____________________________Fax#: __________________________ 2. Name: ._________________________________________ACCT#___________________ Address: .____________________________________________________________ City _________________State:___________________Zip:________ Phone # ._____________________________Fax#: __________________________ 3. Name: ._________________________________________ACCT#___________________ Address: .____________________________________________________________ City _________________State:___________________Zip:________ Phone # ._____________________________Fax#: __________________________ Applicant's signature attests financial responsibility, and willingness to pay our invoices in accordance to invoice terms. Applicant agrees to pay late charges of 1-1/2% per month on balances in arrears. The above information is for the purpose of obtaining credit and is warranted to be true. (I/we) hereby authorize the firm to whom this application is made to investigate teh references listed pertaining to (my/our) crdit and financial responsibilities. Firm Name: ________________________ By: ________________________ Title: ________________________

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