Credit Application – Bulloch Fertilizer

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1Application

2Guaranty Agreement

Full Legal Name

First

Middle

Last

In Business Since

Phone

Doing Business as:

Billing Address

Address Line 1

City

State

Zip Code

Accounts Payable Contact

First

Last

Shipping Address

Address Line 1

City

State

Zip Code

County of the ship to address

Single Line Text

Tax Exempt?

If Yes, a signed Sales & Use Certificate of Exemption must be attached or emailed at the time of submission. Or Gate Card no. listed below.

Is a Purchase Order Required?

Bulloch Fertilizer Co., Inc. utilizes a credit reporting service to process all applications for credit. You MUST provide either a Social Security Number or a Federal ID Number in order for this application to be considered.

Social Security Number/ Federal ID Number

If applying for an individual account

All information listed above is kept in strict confidence at our accounting office located at 205 West Main Street, Statesboro, GA.

By Signing below as applicant, you authorize Bulloch Fertilizer Co., Inc. to investigate your credit history to the extent allowed by law.

Signature

Clear Signature

Title

Date

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