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Marine Chemist Service, Inc.
Application for Credit
Name of Firm or Individual
Street Address
How Long at this Address  Years  Months
City  State  Zip 
Phone Number          (with area code)              Fax Number 
Name of Accounts Payable Contact   Title 
Phone Number  Extension 
Years Incorporated or Registered                     Approximate Annual Sales 
Corporation  Partnership  Sole Proprietor Other 

OWNERSHIP:
Name: Title:
Address: Telephone:
Address:    

TRADE REFERENCES:
Company Name:
Contact Person 1:
Address 1:
Telephone:

BANK REFERENCES:
Name:
Contact Person:
Address:
Telephone:
By submitting this form, I (We) certify that all information on this form is correct to the best of my knowledge. I (We) have not knowingly provided false information. I (We) also understand that an 18% annual finance charge (1.5% monthly) may be applied to any past due invoices.
  
 

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