Credit Application
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Financial Information
Please complete this form if you wish to apply for net 30 credit term.

By submitting this form, I (We) hereby authorize the release of information pertaining to the following accounts and any other accounts held at the following bank/lending institution.
Business name
Bank *
Officer
Phone *
Checking Account
Saving Account
Credit Reference
Please list three floral supplier credit references that you have done business within at least one year.
Creditor 1
Phone
Email
Address
Account Number
Creditor 2
Phone
Email
Address
Account Number
Creditor 3
Phone
Email
Address
Account Number
By submitting this form, I (We) certify that all the information on this form is true and correct. I (We) have been advised Liberty Floral, Inc. payment terms of net 30 days from the invoice date. Being a legal representative for my company, I agree to remit payment to Liberty Floral, Inc. at the address indicated on the invoice within these terms.

I (We) also understand that if payment is not made within these terms future shipment by Liberty Floral may be declined, and that any payments made beyond agreed upon terms will be subject to interest charges.

Name *
Title *
Date *
MM
/
DD
/
YYYY
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