NEW ACCOUNT APPLICATION
(All information must be complete to process application)

Company Name:
D/B/A:
Bill To:
Street:
City:
State/Zip:
Phone#:
Fax#:
Federal Tax#:
Bank Name:
Bank Fax#:

KEY CONTACT INFORMATION

Owner(s):
Email:
Personal Address:
Street:
City:
State/Zip:
Home Phone#:

TYPE OF ACCOUNT REQUESTED

COD Bank/Certified/Money Order
COD Check
Charge-Visa or MasterCard
**Net 30 open account requires further application

CREDIT INFORMATION FOR NET 30 OPEN ACCOUNT
(Please furnish complete information)
If you are not applying for a Net 30 open account, please skip this section

Type of Business: Corporation Partnership        Proprietorship
Amount of credit line requesting:

Federal Tax:

How long in Business:

Phone/Fax:

Name of Bank:

Bank Contact:

Street:

Account#:

City/State/Zip:

 TRADE REFERENCES

Company:

Company:
Street:

Street:
City/State/Zip:

City/State/Zip:
Phone/Fax:

Phone/Fax:
Contact:

Contact:

ADDITIONAL RETAIL LOCATIONS

Street: Street:
City: City:
State/Zip: State/Zip:
Phone/Fax: Phone/Fax:
Contact: Contact:

The submitee hereby bestows upon CTD, Inc., the authority to verify all credit references and other information submitted to CTD, Inc., by the way of attached credit application, and furthermore indemnifies and holds CTD, Inc., harmless from any liability incurred in connection therewith. I, (we) certify that the above information is true and correct and that we can comply with your terms.

Please click submit only once.