Print this form. Fill in completely and return to Nutra-Flo Company.
Nutra-Flo® Company 1919 Grand Avenue -- Sioux City, Iowa 51106-5708 -- Ph: 712-277-2011 -- Fax: 712-279-1946
The following information will be kept in strict CONFIDENCE and will be used only for the purpose noted.
APPLICATION FOR CREDIT
Business Name Date
Address City State Zip
Phone Fax
If company, type of ownership:  Corporation     Partnership     Individual
Federal ID Number
Owner's or Principal's Names:
	SSN	Title
	SSN	Title
	SSN	Title
State Incorporated Year
Are there any other company names?
How long have you been in business? Desired Credit Limit
How long have you been at your present address?
Type of Business Number of employees?
Have you ever filed a personal or business bankruptcy?
SIC Code D&B Number
Are purchase orders required?   Yes     No
Person to contact regarding Accounts Payable
Recent Financial Statement Required:

	Bank Reference	Address	Phone	Banker's Name
1.
2.
3.

Business references you have been recently doing business with:
Name	Address
Phone	City	State	Zip
Name	Address
Phone	City	State	Zip
Name	Address
Phone	City	State	Zip
I (we) understand that the information furnished you on this page is for the purpose of obtaining credit from your firm. That I am (we are) authorized in my (our) capacity, to bind my (our) firm accordingly. All accounts or monies due shall be due and payable at your place of business. I (we) will be personally responsible for any debts incurred.
Signature Title
Signature Title
Signature Title
Terms and Conditions: Terms are net due 15 days from the invoice date. On past due invoices, a late payment charge of 2% will be assessed on the unpaid balance. After 30 days, a service charge of 1½% per month will be charged on all past due balances. In no event will finance charges exceed maximum permissible by law.
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