9 Seminars

Customer Application

Selby's Credit Application

Selby's

2595 Enterprise Ave.

Billings, Montana 59102

Phone: 406-652-4414 Fax: 406-652-7825

Corporation

Partnership

L.L.C.

Other

Check Box if Statement is Required

Company Name:

D.B.A. If Any

P.O. Box

Street Address:

City:

State:

Zip / Postal Code

Phone:

Fax Number:

E-Mail:

Nature Of Business:

Federal Tax I.D. #:

Years In Business:

Number Of Employees: State Of Incorporation:Date:

Principal:

Title:

Home Street Address:

City:

State:Zip:

Social Security Number:

Phone:

% of Ownership:

Additional Owners:

% of Ownership:

Additional Owners:

% of Ownership:

Additional Owners:

% of Ownership:

Additional Owners:

% of Ownership:

Bank Information:

Name Of Bank:

Address Of Bank:

City:

State: Zip:

Phone Number:

Contact Person:

Account Number:

Account Type:

Account Number:

Account Type:

Account Number:

Account Type:


Name Of Bank:

Address Of Bank:

City:

State: Zip:

Phone Number:

Contact Person:

Account Number:

Account Type:

Account Number:

Account Type:

Account Number:

Account Type:

Release

To Whom It May Concern:

This will be your authority and my request for you to release any information requested concerning personal or company credit standing.

Signature:

(Type Name Here)

Trade References:

Name Of Company:

Contact:

City:

State:

Phone:

Name Of Company:

Contact:

City:

State:

Phone:

Name Of Company:

Contact:

City:

State:

Phone:

I certify that the above information is true and correct. I also understand that any and all amounts charged will be paid within 30 days of receipt of invoice. PAST DUE ACCOUNTS ARE SUBJECT TO FINANCE CHARGES OF 1.5% EACH MONTH AN ANNUAL RATE OF 18% . MINIMUM FINANCE CHARGE IS $ 1.00.

I have read and understand

the above information

Signature:

(Corporate Officer or Responsible Party)

(Type Name Here)

Print and Fax to: (406)-652-7825 Attn: Kathy