Name: Contact Name: Address: City/State/Zip: Phone: Fax:

General Business Information

Type of Business:
Years in Business:
(please check one) Corp. Partnership Other
FID or SSN: Tax Exempt: Y N
(If exempt please include a copy of your exemption cert. )
Accounts Payable Contact:
Phone:

Bank References:

Bank Name:
Account Number:
Address:
City/State/Zip:
Contact:
Phone:

Company Trade References:

1st Reference:
Contact:
Address: City/State/Zip:
Phone:
Fax:
2nd Reference: Contact:
Address:
City/State/Zip:
Phone:
Fax:
3rd Reference: Contact:
Address:
City/State/Zip: Phone:
Fax:

Applicant's Signature:__________________________________________________

Title:_________________________________________

Date:___________________

Please Print and Mail to:

Groebner & Associates, Inc.
Attn: Accounts Receivable
9530 Fallon Avenue NE
Monticello, MN 55362