Rent Nation | Create an Account - Application for Credit Account

Application for Credit Account

Date
MM slash DD slash YYYY
Business Type
Business Name
DBA if applicable
Physical Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Accounts Payable Contact
Phone
Email
Owners Name
FED ID#
Type Of Business:
- Partnership
- Corporation
Tax Exempt
- Y
- N
If Yes, please attach certificate
Max. file size: 50 MB.
Bank References
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Trade References
Business
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Customer certifies that all information provided is correct and authorizes indicated bank and business references to verify stated information to Southern Equipment Source, LLC upon request.
Print
Signature
Date
MM slash DD slash YYYY
Title