ATLANTIC CONTROLS CORPORATION
PMB 342
1835 U.S. 1 South 119
St. Augustine, FL 32084
Ph: 904-940-3388 Fax: 904-940-7744

Credit Application----------------------------------------------------------------------------------------------------------------------------------

Name of Business:_____________________________________________________________________

EIN# _____________________________________________

Street Address:________________________________________________________________________

City: State:_________________ Zip:_______________________

Billing address if different: Attn:_______________________

Contact Person in Accounts Payables:______________________________________________________

Accounts Payable Telephone: Fax:________________________

Line of Business: Date Business Started:_________

Please check the box that applies. [] Corporation [] Partnership [] Proprietorship

List names and address of each partner, sole proprietor or officers and directors.

Name address title

________________________________________________________________________________________________
Name address title

______________________________________________________________________________________
Name address title

Business References:

Name of Bank: Account#:__________________________________________
Address:_______________________________________________________________________________
City: State: Zip:_________________________
Phone:( ) Fax:( ) Contact Person:________________

Suppliers References: Fax Numbers are required for your vendors________________________________

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

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

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

ATLANTIC CONTROLS SERVICES
Credit Application
Page 2

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

The foregoing statement and information contained on this application, both written and printed, are full,
true, and correct statements of my financial condition, on date stated. For any transaction, the undersigned agrees to pay all charges based on Net 30 day term from the date of the invoice.

Company Name: Date:_______________________________

Signature of Authorizing Officer: Title:_______________________________

To help serve you better—What is the amount of credit line required?

____________________________________________________