Credit Application  
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Application For Credit

Bill To:
Exact Name:
Division or: Subsidiary
Address:
City, State, Zip ,
Phone

Ship To: (Check here if same as Bill To:)

Name:
Address:
City, State, Zip ,
Phone

General Business Information
Type of Business
D.B.A. Individual    Partnership   Corporation
Years In Business      Year of Inc.      State of Inc.
Officer's Name Title
Officer's Name Title
Are you Sales and/or use tax exempt? No      Yes (If yes, fax certificate of exemption)
Accounts Payable Contact:    Name:
   Number:

Bank Reference
Bank Name
Officer Handling
City, State, Zip ,
Phone
Account Number
Business Credit Reference
1.) Name
City, State, Zip ,
2.) Name
City, State, Zip ,
3.) Name
City, State, Zip ,
By Clicking Submit, you certify that all the information on this form is correct; and that you fully understand your credit terms and agree to the proper payment in consideration of extended credit. You shall be responsible for all costs of collection including but not limited to legal expenses and attorney's fees incurred by Person Eyes Optical Lab in the enforcement of this indebtedness.