Customer Credit Application

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Credit Application for Interested Dealers

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If you want to fax or mail your application please click here for a printable version of the Customer Credit Application

Customer Credit Application


Contact First Name:
Contact Last Name:
Company Name:
Address 1:
Address 2:
City: State: ZipCode:
Phone Number:
Fax Number:
E-Mail:
Tax ID Number:
Bank Name:
Bank Branch:
Bank Phone Number:

Reference #1
Contact:
Company Name:
Address:
City: State: ZipCode:
Phone Number:
Fax Number:

Reference #2
Contact:
Company Name:
Address:
City: State: ZipCode:
Phone Number:
Fax Number:

Reference #3
Contact:
Company Name:
Address:
City: State: ZipCode:
Phone Number:
Fax Number:

By clicking on the "Submit" button below, you authorize Brass Elegans, Inc. to perform a credit check for the purpose of opening credit with us.

An Elegant Touch of Brass