Wizard Distribution, Inc.
15500 Erwin Street Department 1049
Van Nuys, CA 91411
888-346-3826 Fax 818-781-8106

CREDIT APPLICATION
Legal Name of Firm: ______________________________________________

Name of Parent Company of Subsidiary: ______________________________

Principal Business Address: _________________________________________

Phone __________________________ Fax: ___________________________

Type of Business: ___________________ Number of Locations: ______________

Present Ownership Since (Date): ________ Year Business Established: _________

Sole Proprietorship/Corporation/Partnership (circle one)

Officers: _____________________ Owner: ______________________

Vice President: ____________________ State Tax No. _____________________

Bank Reference
Bank: ________________________ Account No. _________________________
Address: _________________________ City:____________________________
State:____________________________ Zip:____________________________

Contact: _____________________ Phone: ______________________________
Secured (Yes No) Personal Guarantee (Yes No)

Additional Trade References

1. Name: _______________ Phone:_____________Address: ________________ City:___________________State:_______________ Zip:___________________


2. Name: _______________ Phone:_____________Address: ________________ City:___________________State:_______________ Zip:___________________


3. Name: _______________ Phone:_____________Address: ________________ City:___________________State:_______________ Zip:___________________

The undersigned hereby certifies that the above information is true and correct and in addition to the foregoing the undersigned promises to personally pay for all purchases in accordance with your terms of sale.

Date: __________________ Company (Legal Name):______________________

By (Signature of Owner, Officer or Authorized Agent):________________________