Customer Credit Application
Name of Business______________________________________________________________________________
Address of Business______________________________________________Telephone______________________
City_______________________ State____________________ Zip___________________ Fax________________

Billing Address
Name of Business______________________________________________________________________________
Address of Business______________________________________________Telephone______________________
City_______________________ State____________________ Zip___________________ Fax________________
E-Mail__________________________________________ A/P Contact___________________________________

Ship to Address
_______________________________________________________________ Telephone______________________
City_______________________ State____________________ Zip___________________

Type of Business

Principals of the Company

Bank Information
Name of Bank__________________________________________________________________________________
Address________________________________ City_____________________ State _________ Zip____________
Telephone__________________________ Fax___________________________ Cell_________________________
Checking account number___________________________ Savings account number________________________
Loan account number______________________________________________

Trade References

With this application you are authorizing Conley’s Mfg & Sales to contact the above references to gain financial
information to establish terms.  With your authorized signature we are authorized to obtain and keep this
information.  For your protection, Conley’s Mfg & Sales asserts that any information gathered is private and
confidential between the applicant and ourselves.  We do not release credit information arbitrarily, nor do we
release our customer list to others.

Conley’s Mfg & Sales retains the right to contract the above given references for future use if necessary. 
The above information may not necessarily reflect your company’s current status, so we may take the liberty
to ask additional questions if necessary.

Authorized Signature:___________________________ Position:_________________________ Date:___________

Terms upon approval: A late charge of 1.5% per month will be added to accounts with balances over stated terms.

A Division of John L. Conley, Inc.
Serving Agriculture Since 1946