CREDIT APPLICATION

We are please to open a Burkhart's Charge Account to qualified individuals and companies. Please fill out all information in the form below and one of our credit representatives will contact you.

ACCOUNT INFO

Company Name

Your Name

Street Address

Mailing Address

City, State, Zip

Your E-Mail

Phone number

Fax number

Owner or Principal

Are you Tax Exempt?

Name #1

Name #2

Name #3

Name #4

Name #5

Name #6

CREDIT REFERENCES
Vendors or Suppliers other than Banks, Utilities or Credit Cards.

REFERENCE #1

Company Name

Street Address

City, State, Zip

Phone number

REFERENCE #2

Company Name

Street Address

City, State, Zip

Phone number

REFERENCE #3

Company Name

Street Address

City, State, Zip

Phone number