Credit Application
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.

Bank *
Your answer
Officer
Your answer
Phone *
Your answer
Checking Account
Your answer
Saving Account
Your answer
Credit Reference
Please list three floral supplier credit references that you have done business within at least one year.
Creditor 1
Your answer
Phone
Your answer
Email
Your answer
Address
Your answer
Account Number
Your answer
Creditor 2
Your answer
Phone
Your answer
Email
Your answer
Address
Your answer
Account Number
Your answer
Creditor 3
Your answer
Phone
Your answer
Email
Your answer
Address
Your answer
Account Number
Your answer
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 *
Your answer
Title *
Your answer
Date *
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