New Customer Credit Authorization Form - Caspers Service Company

General Information

Customer Name*

(dba) Trade Name

Phone Number*

Fax Number

Physical Address*

City*

State*

Zipcode*

Business Information

CorporationLLCPartnershipProprietorship

Length of Time in Business*

D&B #*

Fed ID (FEIN)*

Nature of Business*

Previous Business Names
If Partnership or LLC, list partners/members

Accounting Information

Accounts Payable Contact*

Accounts Payable Phone Number*

Accounts Payable Email*

Accounts Payable Fax Number*

Authorized Buyers*
Are Purchase Orders Required?YesNo
Are Job #’s Required?YesNo
Able to receive email statements and invoices?YesNo

Credit References

Bank*
Vendor/Supplier 1*

Vendor/Supplier 2*

Authorization and Release to Obtain Personal Credit InformationBy checking this box, the customer hereby attests that he/she is an authorized principal and/or sole proprietor of the business referenced above (the “Company”), and consents to Caspers Service Company, LLC, its designee, assigns or potential assigns (“CSC”), obtaining a consumer credit report on the undersigned from any consumer reporting agency and/or bureaus that CSC may choose to use and to consider such report when evaluating the creditworthiness of the Company. The undersigned understands that he/she is not obligated to provide CSC with authorization to review such consumer report. However, the undersigned voluntarily agrees that his/her individual credit history may be a factor in the evaluation of the creditworthiness of the Company and such report can be released to CSC for the purpose of it considering whether to transact business with the Company. While information appearing on the undersigned’s credit report may be used as a factor in evaluating the creditworthiness of the Company, the undersigned understands that the report accessed by CSC will not affect his/her credit score. The undersigned further authorizes the bank and vendor/supplier references listed above to release all relevant credit information to CSC, including balance and transaction history, so that it can be used to evaluate his/her credit history. In the event, CSC decides not to do business with the Company as a result of any information contained in a consumer report or credit reference, CSC will supply the undersigned with the specific reasons for the decision. The undersigned verifies that all of the information contained in this Customer Information Sheet are true and correct and further agrees that if any of the information becomes outdated or if the undersigned learns of a potential change in the ownership or management structure of the Company, he/she will promptly notify CSC. The undersigned agrees that a photocopy, scan or facsimile copy of this authorization and release may be accepted with the same authority as the original.