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February 2-5, 2012

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Albuquerque, NM

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Blue Gem Sunglasses, Inc.
CREDIT APPLICATION

BUSINESS INFORMATION
Business/Company Name:

BILL TO
Address:
City, State Zip

SHIP TO
Address:
City, State Zip

ACCOUNTS PAYABLE CONTACT
Name
Phone Number:
Fax Number:
Email Address:

BUYERS NAME
Name
Phone Number:
Fax Number:
Email Address:

NAME OF OWNER
Type of Business: (Check all that apply) Corporation Partnership Sole Proprietor
Years in Business :
Years at Current Location:
Dun and Bradstreet Number:
California Resale Number:

BANK INFORMATION
Bank Name:
Address:
City, State Zip
Phone Number:
Fax Number:
Email Address:
Contact Person:
Account Number:

BUSINESS REFERENCES
Please note: Most businesses only do credit references via fax. Please include each company’s fax number in order to expedite the referral process. Please do not use personal references or credit cards.
NAME #1:
Address:
City, State Zip
Phone Number:
Fax Number:

NAME #2:
Address:
City, State Zip
Phone Number:
Fax Number:

NAME #3:
Address:
City, State Zip
Phone Number:
Fax Number:

Submitting this form certifies that you have accepted to release the above information to Blue Gem, Inc, for the purpose of credit application.