BLOODWORTH WHOLESALE DRUGS
APPLICATION FOR CREDIT
P.O.
PHONE:
229.382.8925
Fax: 229.382.6312
PRINT
THIS FORM AND FAX OR MAIL TO THE ABOVE
Section I:
General Information
Account Name:_________________________________________________________
Business Address:_______________________________________________________
City:_________________________________________________________________
State:________________________________________________________________
Zip:__________________________________________________________________
Phone:_______________________________________________________________
Fax:_________________________________________________________________
Billing Address (If Different):_______________________________________________
Section II: Business Information
Type of Business:_______________________________________________________
Business (Circle Only One): 1.Corporation 2.Partnership 3.Sole Proprietorship
No of Years in Business:__________________________________________________
Federal Tax ID:_________________________________________________________
DEA Number:__________________________________________________________
DEA Expiration:________________________________________________________
Section III: Owner Information
Officers/Owners/Presidents:_______________________________________________
Social Security No.______________________________________________________
Home Address:_________________________________________________________
City:_________________________________________________________________
State:________________________________________________________________
Zip:__________________________________________________________________
Vice President:_________________________________________________________
Social Security No.______________________________________________________
Home Address:_________________________________________________________
City:_________________________________________________________________
(continued)
State:________________________________________________________________
Zip:__________________________________________________________________
Accounts Payable Contact:________________________________________________
Secretary Treasurer:_____________________________________________________
Section IV: Bank Information
Bank Name:___________________________________________________________
Address:______________________________________________________________
Account No.:__________________________________________________________
Officer:_______________________________________________________________
Section V: References
Please List Three Trade References:
1.Name:______________________________________________________________
Account No:___________________________________________________________
Contact Name and Phone Number:__________________________________________
2.Name:______________________________________________________________
Account No:___________________________________________________________
Contact Name and Phone Number:__________________________________________
3.Name:______________________________________________________________
Account No:___________________________________________________________
Contact Name and Phone Number:__________________________________________
Type of Account Desired (Circle One): 1.Open 2.C.O.D.
Owner (Please Print):____________________________________________________
E-Mail Address:________________________________________________________
Signature of Owner:_____________________________________________________