CREDIT APPLICATION
Zircar Zirconia, Inc.
P.O. Box 287
Florida, NY 10921-0287
Tel: (845) 651-3040 Fax: (845) 651-0074
Email: sales@zircarzirconia.com
 
Your company has requested credit with Zircar Zirconia, Inc. Please complete this form and mail or fax back to the above address

 
Company Infomation
 
Company Name:
 
Billing Address:
 
Shipping Address:
Contact:
 
Title:
 
Phone:
 
Fax:
 
Nature of Business:
 
Duns#:
 
Federal ID#:
 
Incorporated:   yes   no
 
Year Incorporated:
 
State Incorporated:
 
Credit Requested$:
 

Trade References: Include three U.S. Firms with which you have done business for more than a year
 
Company:
 
Address:
Company:
 
Address:
Company:
 
Address:
Contact Name:
 
Title:
 
Phone / Fax:
Contact Name:
 
Title:
 
Phone / Fax:
Contact Name:
 
Title:
 
Phone / Fax:
 

Bank Referrence:
 
Contact Name / Title:
Address:
 

I, THE UNDERSIGNED, CERTIFY THAT:

The above information is correct and I am applying for credit with Zircar Zirconia, Inc. I understand that Zircar Zirconia, Inc. will conduct a credit investigation and will contact trade the references supplied above, as well as utilizing reports from outside agencies. The signor certifies that they have read our Terms and Conditions and are authorized commit the above named applicant to these terms.

Signature:
Title:
Date: