Company Information
Company Name
Company Phone
Company Fax
Street Address
State    Zip Code
Email Address
Type of Business
Number of Years
in Business
Owner / Officer Information
% of Ownership
Social Security Number
Home Address
State    Zip Code
Home Phone

Please list any other
owners information here

Bank References
Bank Name
Contact Name
Phone Number
Account Number
Date Opened
Trade References
Trade Name #1
Phone Number
Contact Name
Trade Name #2
Phone Number
Contact Name
Lease / Loan References
Creditor Name
Contact Name
Phone Number
Loan Number
Date Opened
Loan Amount
Vendor & Equipment Info.
Vendor Name
Contact Name
Phone Number
Equipment Cost
Referral Information
How were
you referred
to EPDM Coatingst
Who is your
EPDM Coatings
Sales Executive
Declaration / Authorization
Signer Name
Personal Guraantee Signer if Business is less than 5 yrs old


By submitting this information electronically to EPDM Coatings, you certify that the information is complete and true.  You authorize EPDM Coatings to investigate your credit and employment history, obtain credit reports, and release information about their credit experience with you.

I Agree     I Disagree

In submitting this application electronically, you and any individual identified above who is either a principal, a personal guarantor or a sole proprietor of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, either has provided or hereby does provide his/her authorization for inquiry into their credit worthiness, including but not limited to obtain a consumer credit report, and shall hold EPDM Coatings and its assignees harmless from same. You certify that all the information you have given or will give with this application is true and complete. You authorize us to verify all your statements with any source, obtain credit and employment history, and exchange information with others about your credit and account experiences. EPDM COATINGS is authorized to disclose to the proper person and bureau Applicant's performance of this agreement. In the event of default hereunder, the Applicant agrees to pay court costs and reasonable attorney's fees. This document and all information secured pursuant to its authority shall be and remain the property of EPDM COATINGS whether or not credit is granted hereunder.