Please fax your request to:
								1-843-651-2877
			On-line Credit Application for Net Terms
	Corporate Name							D/B/A:
	Buyer/Owner:							Phone:
								Fax:
	Billing Address:							E-Mail:
			City:				State:		Zip:
	Shipping Address:
			City:				State:		Zip:
	Federal Tax ID #/SSN:
					Banking Information
	Bank Name:						Account Number:
	Contact:							Phone:
	Address:						City:
							State:		Zip:
					Trade References
	Co. Name:						Co. Name:
	Account #:						Account #:
	Address:						Address:
	City:						City:
	State:		Zip:				State:		Zip:
	Phone:						Phone:
	Fax:						Fax:
	Co. Name:						Co. Name:
	Account #:						Account #:
	Address:						Address:
	City:						City:
	State:		Zip:				State:		Zip:
	Phone:						Phone:
	Fax:						Fax:
	The individual signing this application is an authorized representative of the client company and agrees that "Cruz" may verify the company's credit history
	or verify my personal credit history.  I understand that upon my request, "Cruz" will inform me of the name and the address of each consumer reporting agency
	from which it obtained a credit report.  The undersigned also understands that "Cruz" will not divuldge any credit information to unauthorized parties.
	Name and Signature of Authorized Contact:								Date: