| J. W. TOUPS INC. Back
to Home Page CREDIT APPLICATION Please complete this form and mail it back to P. O. Drawer 1235, Thibodaux, LA 70302 Or fax to (985) 447-5183 Company Name: ____________________________Contact Person: _____________________ Dunn and Bradstreet Number _________________ Mailing Address: ____________________________________________________ City: ____________________ State: ___________ Zip Code: _______________ Street Address: _____________________________________________________ City: _____________________ State: ___________ Zip Code: _______________ Phone Number: _____________________ Fax Number: ____________________ Phone Number of Bank: __________________ Bank Contact: _________________________ Date Business was established: ________________Federal Tax ID #: ___________________ President or CEO: ___________________________________ Company Name & Address: _____________________________________________ Phone #: ________________ Fax #: _______________ Account #: _____________ Company Name & Address: _____________________________________________ Phone #: ________________ Fax #: _______________ Account #: _____________ Company Name & Address: _____________________________________________ Phone #: ________________ Fax #: _______________ Account #: _____________ Company Name & Address: _____________________________________________ Phone #: ________________ Fax #: _______________ Account #: _____________ The above information will be kept confidential and will not be used
for solicitation purposes. |