Westfield Home Center
605 W. Main P.O. Box 1096 Gravette, AR 72736
(479) 787-5845 fax (479) 787-7845
Credit Application
Name:___________________________________________Date:___________________________
Address:_______________________________City:_______________State:_____ZIP:__________
Phone:___________________Cell:____________________SSN/TID:________________________
If Company, type of ownership: ______Corporation _____Partnership _____Individual
Principal Owners/Corporate Officers:___________________________________________________
Bank Reference:
Name of Bank:__________________________________Type of Account:____________________
Address:_____________________________________________Phone:______________________
Contact Name:_________________________________________Fax:_______________________
Name of Bank:__________________________________Type of Account:____________________
Address:_____________________________________________Phone:______________________
Contact Name:_________________________________________Fax:_______________________
Credit References:
Name:___________________________________________Phone:__________________________
Address:________________________________________________Fax:_____________________
Name:___________________________________________Phone:__________________________
Address:________________________________________________Fax:_____________________
Name:___________________________________________Phone:__________________________
Address:________________________________________________Fax:_____________________
Name:___________________________________________Phone:__________________________
Address:________________________________________________Fax:_____________________
I understand that by signing this credit application, I hereby give Westfield Home Center, Inc. permission to obtain information as to my creditworthiness. I also understand that by my completion of this application that Westfield Home Center in no way guarantees extension of credit. I understand that Westfield Home Center does not discriminate in the extension of credit based on sex, age, marital status, or any other circumstance protected be federal law. I also understand that if credit is granted to me that all payments are due in full by the 10th day of the month and that if my account becomes delinquent that Westfield Home Center, Inc. will pursue all legal remedies available to collect on my account and that I will be responsible for all attorney’s fees, court fees, and service charges related to collection. I understand that the information given in this credit application will be held in the strictest of confidence and used only by the credit department of Westfield Home Center.
Signature:______________________________Title:__________________Date:_______________