® 
The Complete Wholesale Line of  Terminals, Wire and Wiring Devices,  Nationwide
Automotive - Truck - Marine - Farm - Industrial		 Made in the U.S.A.
1620 32nd St.
Springfield, OR 97478
(800) 547-4711
FAX (541) 744-1173
Phone (541) 744-0630

CREDIT APPLICATION  (Please fill out completely and PRINT or TYPE)

Bill To: Name: ___________________________________________________________________
 
Street Address: _____________________________________ PO Box: ______________
 
City: ______________________________ State: _______ Zip: _________________
 
Phone: ____________________________ Fax: ____________________________

Ship To: Name: ___________________________________________________________________
 
Street Address: _____________________________________ PO Box: ______________
 
City: ______________________________ State: _______ Zip: _________________
 
Phone: ____________________________ Fax: ____________________________

Business:
Type: ____________________________________________ Date Started: ___/___/___
 
Sales Tax Resale Permit #: _________________ Acct. Payable Contact: _________________
 
Name of President or Owner: (Print) ________________________________________
 
Partnerships - Name of Partner: (Print) ________________________________________

Banking: Name & Address: __________________________________________________________
 
Account #: ___________________________ Bank Phone #: _____________________
 
Contact Name: ________________________ Bank Fax  #: ______________________

List THREE REFERENCES who have each extended you $1000.00 minimum credit in the past six months. (We can process your request faster if you supply fax numbers.)

___________________________________________________
1. Name		 ___________________________________________________
Mailing Address
____________________
Phone		 ____________________
Fax (Recommended)
___________________________________________________
City, State, Zip
___________________________________________________
2. Name		 ___________________________________________________
Mailing Address
____________________
Phone		 ____________________
Fax (Recommended)
___________________________________________________
City, State, Zip
___________________________________________________
3. Name		 ___________________________________________________
Mailing Address
____________________
Phone		 ____________________
Fax (Recommended)
___________________________________________________
City, State, Zip
 

This signature authorizes the release of credit information to Noble Wire & Terminal Corp. The undersigned agrees to accept the order of merchandise as represented by the representative of Noble Wire & Terminal, Corp. and understands that if for any reason the shipment is refused the above named company shall agree to pay the shipping cost both ways.

________________________________ 
Signature of Owner or Officer		 __________________
Phone		 ___/___/___
Date