Buckley Rumford Fireplaces
Dealer Credit Application
7/25/14

Print out and complete form, and mail or fax to:

Buckley Rumford Fireplaces
1035 Monroe Street
Port Townsend, WA 98368
360 385 9974 (fax 360 385 1624)
buckley@rumford.com

Name of company_________________________________________________
Address_________________________________________________________
________________________________________________________________
Phone______________________________FAX_________________________

Company is a Corporation______, Partnership_______, or Proprietorship_____
Tax ID number___________________ Number of years in business__________

Company officers________________________ _________________________
_______________________________________ _________________________

Bank name________________________ Officer's name __________________
Bank address_____________________________ Phone__________________
Bank account numbers_____________________ _________________________

Trade references:
1. _________________________________ ____________________________
2. _________________________________ ____________________________
3. _________________________________ ____________________________

Are there suits for debts owed or unsatisfied judgements against the company or has
the company or any entity controlled by the company been declared bankrupt within
the last ten years?_________ If yes, explain
_________________________________________________________________
_________________________________________________________________

Authorized Signor_____________________________ Date__________________

Title___________________________

Office use only

Approved_______________________ Limit __________________ Date ________
Not approved____________________ Reason_________________ Date ________

Buckley Rumford Fireplaces
Copyright 1995 - 2014 Jim Buckley
All rights reserved.
webmaster