Western Professional Purchasing







2029 Bluegrass Cir. P.O. Box 20125 Cheyenne, Wy 82003 1-800-735-8312

Credit Information

CREDIT INFORMATION

PRACTICE LEGAL NAME:

_______________________________________________________________

DBA NAME: (IF DIFFERENT THAN ABOVE)

_______________________________________________________________

NAME OF RESPONSIBLE PERSON:

_______________________________________________________________

CITY,STATE,ZIP:________________________________________________

PHONE: ___________________FAX:____________________

E-MAIL ADDRESS:_______________________________

PLEASE LIST THE NAME OF AT LEAST THREE SUPPLIERS YOU ARE CURRENTLY DOING BUSINESS WITH

_____________________________________ACC #__________________

BANK NAME:___________________________ACC #__________________

HAVE YOU EVER DECLARED BANKRUPTCY? YES___ NO ___

ARE YOU INVOLVED IN ANY LAWSUITS OR ARE THERE ANY PENDING WHICH MAY AFFECT YOUR ABILITY TO PAY FOR THE PURCHASES YOU MAY MAKE AS A MEMBER OF THE GROUP? YES ___NO ___