Credit Application

- Submitted By
- Legal Name of Firm*
- Trade Name or DBA
Billing Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Service Address
If different than Business Address
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Federal ID*
- Email Address*
- Phone #*
- Fax #
- Form of Organization*
- Primary Line of Business*
- Number of Employees
- Years in Business*
- Retail Sales Tax/Exemption #
- Resale/Exemption Certificate

- Name 1*
- Title 1*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Name 2
- Title 2
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank References
Data Entry Method*
Bank 1 Name*
Contact Name*
Branch Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone #*
Fax #
Account #*
Account Type*
Upload Bank References*
Drop files here or

Business References Where Credit Is Extended
Data Entry Method*
Business 1 Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone #
Fax #*
Name
First Last
Email Address*
Business 2 Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone #
Fax #
Email Address
Upload Business References*
Drop files here or
All accounts are due and payable Net 30 days. Credit terms are subject to periodic review and may be modified at the discretion of BluEdge. All costs incurred for collection including reasonable attorney fees will be paid by the applicant.

Billing Address