'Excellence in Chemical Distribution'

ICC Credit Application Form

Thank you for applying for a line of credit with us. Please fill out the following credit application as completely as possible for our review. The more complete the application, the faster it will process. We will be contacting you shortly.

If you have any questions about the form, please contact Ruby Tsaousis at Accounts Receivable by e-mail to rubyt@independentchemical.com

 

 


Business Information



When was business established?




Tax Information

Type of Ownership:  

Has the firm or any of its Principals ever been bankrupt?  


CORPORATE OFFICER CONTACT INFORMATION


PURCHASING CONTACT INFORMATION


WAREHOUSE CONTACT INFORMATION


ACCOUNTS PAYABLE CONTACT INFORMATION


TRADE REFERENCES

(Names of suppliers of major products and services)
Company Name/Address/Phone/Fax/Contact

Reference Details # 1



BANK REFERENCES

Reference Details # 1

Type of Account:  



SIGNATURE

Please upload an image file with an authorized signature to have bank release information. (TBD)


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