2390 Blackhawk Road
Rockford, Illinois 61109
Phone: 815-874-7821
Fax: 815-873-4659
Email Address:
CREDIT APPLICATION
Legal Name
Business Name if different Date
Billing Address Shipping Address
(Please specify if more than one)
Telephone # Fax #
E-mail / Website Address
Business Structure
Doing business as ( ) Corporation ( ) Partnership ( ) Proprietorship ( ) Other______
( ) Division of ( ) Subsidiary of
Primary business: Dealer Distributor Manufacturer Other
What is your business’ SIC Code?
Federal ID# Duns #
Date Established ______
Principals or Partners of the Business (Please Print)
Name Title Street Address/City/State Social Security #
Bank Reference
Bank Name ______Bank Phone ______
Mailing Address ______Bank Fax ______
City \ State \ Zip ______Account #______
Expected Monthly Purchases
Trade References (minimum 4)
Reference #1 Reference #2
Name ______
Address ______
City/St/Zip ______
Phone # ______
Fax # ______
E-mail ______
Reference #3 Reference #4
Name ______
Address ______
City/St/Zip ______
Phone # ______
Fax # ______
E-mail ______
Are you tax-exempt? Yes ( ) No ( )
If yes, please attach a sales tax exemption certificate.
Are you capable of sending orders via EDI? Yes ( ) No ( )
Are you capable of remitting payment via ACH or wire? Yes ( ) No ( )
Accounts Payable Contact
Phone Number Fax Number
E-mail Address
Credit Agreement: Applicant’s signature attests financial responsibility, ability, and willingness to pay our invoices in accordance with acknowledged terms of NET 30 DAYS FROM DATE OF THE INVOICE. Customer agrees to pay any costs incurred in enforcing Bergstrom’s terms, or in collecting amounts due, including, but not limited to, collection agency fees or commissions, costs of suit and reasonable attorneys fees. Amounts collected shall be applied first to costs of collection or enforcement, as described herein and then to the purchase price.
Authorization: I hearby authorize the above named firms and banking institutions to furnish information requested by Bergstrom to process this application and I agree that the said persons shall not be liable for any claim of damages as a result of furnishing the request for information.
Signature ______Title ______
Date ______
FOR INTERNAL USE ONLY
Originated by ______Date
Bergstrom Inc. Credit Application Page 2 of 2