Name/Address

Company Information

Authorized Puchaser

Financial Information

Accounts payable

Bank References

Domestic Trade References

Foreign Trade References

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine new account approval. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to Distritech, LLC and/or its affiliates in order to verify the information contained herein.



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