Credit Application

  1. Print a copy of this form.
  2. Fill out the form.
  3. Mail to:

Ergo-Health
2230 Pacific Ave
Stockton, CA   95204

Company Name
Address
City State Zip
Phone Fax
Type of Business
Corporation Proprietor Partnership Franchise
No. of Years in Business At Location Since
Purchase Order Required? Federal ID # State ID#

                   Names of Company Officers

Name Title:
SSN City Zip
Name Title:
SSN City Zip

                   Bank Reference:

Bank Name Acct #
Contact Name Type of Account
Address
City State Zip
Phone Fax

                  Trade References:

Name Acct #
Address
City State Zip
Phone Fax
Name Acct #
Address
City State Zip
Phone Fax
Name Acct #
Address
City State Zip
Phone Fax

 

Signed: Title:
Printed: Date:

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