BLUE AMERICA

1360 Valley Vista Dr. Suite #205,

Diamond Bar, CA 91765

Phone:909-396-7373
Fax: 909-396-7374

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

CREDIT APPICATION

Please fill out our online form entirely, and we will get a response back as soon as we can on approval status. If you prefer, please download the PDF of our credit application form, fill it out, and FAX it back to us at: 909-396-7374

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Legal Name of Applicant* Type of Business* Sole Proprietorship Partnership Corporation

In Business Since* Credit Line & term Requested* Duns Number* Federal Tax ID Number*

Street Address* City* State* Zip* Phone Number*

Mailing Address* City* State* Zip* Fax Number

Owner/President’s Name* Home Address* Home Phone Number* Social Security Number*

Purchaser’s Name* E-mail Address* Contact Phone Number* Contact Fax number, if any

A/Payable* E-mail Address* Contact Phone Number* Contact Fax number, if any

Trade References

1) Name* Address* City* State* Zip* Phone Number* Fax Number E-mail address*

2) Name* Address* City* State* Zip* Phone Number* Fax Number E-mail address*

3) Name* Address* City* State* Zip* Phone Number* Fax Number E-mail address*

Bank References

Bank Name* Address* City* State* Zip* Phone Number* Fax Number

Checking Account Number* Savings Account Number Contact’s Name & Title*

The above information is for the purpose of obtaining a line of credit and is warranted to be true. I/We authorize Blue America to investigate the references listed pertaining to my/our credit and financial responsibility, and authorize my/our bank to release the information requested in conjunction with establishing this line of credit. I/we further attest financial responsibility to paying invoices according to the terms of sale established by Blue America.

I agree all above statements.* Yes

CONTACT US

BLUE AMERICA

CREDIT APPICATION

Trade References

Bank References

Thank you for submitting your application!

We will get back you soon.