Please Select One:
Corporation Partnership Proprietorship D&B #/Rating

Company Name
Billing Address:
Address
City State Zip

Usual Shipping Address:
Address
City State Zip
Phone Fax (800)
EMail Address Business Type
Home Office City & State #Years in Business
Federal ID or Social Security #
Illinois Sales Tax Exemption # (Please Send Signed Form)

Contacts:
Purchasing:
Name Title
Phone Fax EMail

A/P Manager:
Name Title
Phone Fax EMail

Principal/Manager:
Name Title
Phone Fax EMail

Trade References:
1. Company Name Account #
Address
Contact Phone Fax
EMail

2. Company Name Account #
Address
Contact Phone Fax
EMail

3. Company Name Account #
Address
Contact Phone Fax
EMail

The above information is warranted to be true and is given for the purpose of obtaining credit for the applicant named above from Textile Industries. In consideration for extension of credit, the applicant agrees to pay all invoices for purchases made by applicant per invoice terms from date of shipment. FOB Shipping Point. Invoices that are past due will be subject to a 1 1/2% per month service charge. In the event legal action is instituted in the collection of unpaid balances, the applicant agrees to pay Textile Industries all costs of collection, including court costs and attorney's fees.

I have read the above terms and conditions and by submitting this form agree to them.
Name Title Date

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