Credit Application

Customer Information

* Indicates required field

Name of Owner *

First

Last

Social Security# *

Company Name *

TAX ID *

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Fax Number *

Cell Number *

Email *

Years in Business *

Type of Business *

PACA License# *

Bank Information

Bank Name *

Bank Account Number *

Bank Address *

Line 1

Line 2

City

State

Zip Code

Country

Bank Contact *

Bank Phone Number *

Have You Applied in The New York Produce Trade Association for Credit *

Yes No

Market References

Name of Contact Person *

Telephone *

Name of Contact Person *

Telephone *

Name of Contact Person *

Telephone *

Business References

Company *

Telephone *

Company *

Telephone *

Company *

Telephone *

BY HITTING SUBMIT BELOW, I, ON BEHALF OF MYSELF AND AS AN AUTHORIZED REPRESENTATIVE OF CUSTOMER,AUTHORIZE THE NEW YORK PRODUCE TRADE ASSOCIATION, INC, AND ITS AFFILIATES AND MEMBERS TO INVESTIGATE THE BUSINESS/PERSONAL CREDIT AND FINANCIAL RECORDS OF CUSTOMER AND ITS PRINCIPAL(S) AND TO MAKE CREDIT INQUIRIES FROM ANY AND ALL CREDIT/TRADE SOURCES IN CONNECTION WITH THIS AGREEMENT.

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