Van Vliet New york Group

Year Started   State of Inc  Federal I.D.#:  
Web Site Address:  
Email( Buyer)  
A/P Contact (bookkeeper)   A/P Email  
A/P Phone:  
Estimated Monthly Purchases. $  
Name of Company Principal Responsible for all Business Transactions   
Title :   Tel:  
Mobile :  

Bank References

Type of Account   Checking No    Saving No    Loan No  

Trade References

You represent you are an authorized representative with authority to enter into this agreement and the information contained in this Application and any attachment is true, correct and complete. You consent to Van Vliet New York obtaining information about the Company from credit reporting agencies and other sources Van Vliet New York deems appropriate in considering this Application. If credit is extended, you agree to be bound by all of the terms and conditions posted on Van Vliet New York’s website.
  • Signature of owner, partner, or authorized person of purchaser
  • Date
  • Title