ChuckleBerries ---- Credit Application

Please Print FILL OUT and FAX the following Credit Application Form to (928-775-0228); to obtain wholesale buyer credit terms with ChuckleBerries. We will confirm receipt of this application for credit within 24 hours. Any missing information will result in delays processing your credit application. All information submitted will be kept confidential.

Name

Company Name

Tax ID Number (must be valid)

Phone (include area code)

Fax (include area code)

Email (yourname@yourserver.com)

Address (office or billing)

Address (shipping, if different than above)

Business Ownership

Business Classification

Ever filed for bankruptcy?

If so, please indicate which year and state?

Amount of Credit Desired

Bank Name

Bank Account Number (required, see note below)

For security purposes, please split your account number between the two fields above; e.g., if your account number is 12345678, you could enter 123 in the first field and 45678 in the second field, or 12345 in the first field and 678 in the second field. Include hyphens/dashes if they are in your account number.

Bank Address (include street, city, state and ZIP)

Bank Phone Number (include area code)

Bank Contact Person

By submitting this form, do you agree to let ChuckleBerries contact your bank to check your company's credit and financial history to the extent required to grant your company credit?

Trade Reference A: Company Name

Company Address (include street, city, state and ZIP)

Company Phone (include area code)

Contact Person

Trade Reference B: Company Name

Company Address (include street, city, state and ZIP)

Company Phone (include area code)

Contact Person

Trade Reference C: Company Name

Company Address (include street, city, state and ZIP)

Company Phone (include area code)

Signature (MUST BE SIGNED)

If you have questions about this Credit Application Form, please contact ChuckleBerries by the following methods:

Mail: ChuckleBerries
13825 E. Wildcat Way
Prescott Valley, AZ 86314

Phone and Fax:
928-775-6906 --- Phone
928-775-0228 --- Fax

Email:
cbpreemiew@netscape.net



			ChuckleBerries -- Credit Application Form Please Print FILL OUT and FAX the following Credit Application Form to (928-775-0228); to obtain wholesale buyer credit terms with ChuckleBerries. We will confirm receipt of this application for credit within 24 hours. Any missing information will result in delays processing your credit application. All information submitted will be kept confidential. Name Company Name Tax ID Number (must be valid) Phone (include area code) Fax (include area code) Email (yourname@yourserver.com) Address (office or billing) Address (shipping, if different than above) Business Ownership Business Classification Ever filed for bankruptcy? If so, please indicate which year and state? Amount of Credit Desired Bank Name Bank Account Number (required, see note below) For security purposes, please split your account number between the two fields above; e.g., if your account number is 12345678, you could enter 123 in the first field and 45678 in the second field, or 12345 in the first field and 678 in the second field. Include hyphens/dashes if they are in your account number. Bank Address (include street, city, state and ZIP) Bank Phone Number (include area code) Bank Contact Person By submitting this form, do you agree to let ChuckleBerries contact your bank to check your company's credit and financial history to the extent required to grant your company credit? Trade Reference A: Company Name Company Address (include street, city, state and ZIP) Company Phone (include area code) Contact Person Trade Reference B: Company Name Company Address (include street, city, state and ZIP) Company Phone (include area code) Contact Person Trade Reference C: Company Name Company Address (include street, city, state and ZIP) Company Phone (include area code) Signature (MUST BE SIGNED) If you have questions about this Credit Application Form, please contact ChuckleBerries by the following methods: Mail: ChuckleBerries 13825 E. Wildcat Way Prescott Valley, AZ 86314 Phone and Fax: 928-775-6906 --- Phone 928-775-0228 --- Fax Email: cbpreemiew@netscape.net




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