Pacific Ag Products
400 Capitol Mall, Ste 2060
Sacramento, CA 95814
Ph: 916-403-2123
Fax: 916-446-3925
Line of Credit Requested $
Date
Business Name
Remit to Address
Email Address
Phone No.
Fax
Shipping Address
How many years
Federal Tax ID #
D/B/A
How long in Business
Former Business (if less than 1 year)
Type of Business
Does the State or Country require a license:
Yes
No
if Yes #
No of Employees
Est. Annual Sales
Sales Area
Sole Proprietor
Partnership
Cooperative
Corporation
Principals
(NAME)
(TITLE)
(ADDRESS)
(SOCIAL SECURITY #)
(NAME)
(TITLE)
(ADDRESS)
(SOCIAL SECURITY #)
(NAME)
(TITLE)
(ADDRESS)
(SOCIAL SECURITY #)
Has the Firm or any of its principal partners ever filed for Bankruptcy?
Yes
No
If Yes Explain
Account Payable Contact Name
Trade References
Name
Address
Contact
Tel. #
1
st
2
nd
3
rd
4
th
Bank References
Name
Address
Checking
Amortized Loan
Line of Credit
Savings
Phone #
Account #
Contact
