Name of Firm:

Ship To Street Address:

Bill To Address:

County:

Firm is a: Corporation Partnership Proprietorship

Name of Officers or Owners of Firm

Person To Contact for:

Purchase Orders - Name/Title
Phone (include area code):
.
Payments - Name/Title
Phone (include area code):

Tax Permit Number:

References:

Bank Name:
Bank - City / State:
Bank Phone # (include area code):
.
Trade Reference 1 - Name:
Trade Reference 1 - City / State:
Trade Reference 1 - Phone # (include area code):
.
Trade Reference 2 - Name:
Trade Reference 2 - City / State:
Trade Reference 2 - Phone # (include area code):
.
Trade Reference 3 - Name
Trade Reference 3 - City / State:
Trade Reference 3 - Phone # (include area code):

Estimated Line of Credit Applied For $: 

Note: If estimated line of credit exceeds $10,000 a current financial statement and a prior year audited statement should be sent to us at: P.O. box 1229, Anniston, AL 36202-1229
         If the account is not paid in full as agreed and legal recourse is required, applicant agrees to pay all costs and expenses of collection, including actual attorney's fees, and shall also pay costs, expenses and attorney's fees incurred on appeal.
          The undersigned certifies the above information to be correct, that it is submitted for the purpose of obtaining credit, and agrees to all of the terms and conditions of Lee Brass Company.  A service charge of 1.5% per month (Annual Rate of 18%) will be added to all invoices not paid within our terms.
Please type your name, title, and date below (a typed name constitutes a signature):

NAME:
TITLE:
DATE:

Customer Contact Information
Name of contact:
Phone number (include area code):
Phone extension: 
FAX number (include area code): 
E-mail address: (required) 

Alternate contact: 
Phone number (include area code):
Phone extension: 
FAX number (include area code): 
E-mail address: