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Credit Application

Please print this form, fill out and fax to Diedrich Drill at 219-324-5962
  • Date:    Federal ID#
  • Company Name  Division or
  • P.O. Box               Subsidiary of
  • Physical Address  PhoneFax
  • CityState   Zip Code
  • Type Of Organization:IndividualPartnershipCorporationLLC
  • Type of Business:
  • Date established under present ownership
  • Principals:                   Name
  • Purchasing Agent
  • Accounts Payable Supervisor

  We understand that an invoice is considered past due if not paid within the terms stated on the invoice and that service charges may be assessed on all past due invoices. We do hereby agree to pay the same. The undersigned further agrees to pay all expenses, and attorney fees paid or incurred by Diedrich Drill, Inc. in endeavoring to collect sums due and owing by the company.

  We grant permission for any person or reporting agency to furnish Diedrich Drill, Inc. all information which may be periodically requested. I understand that credit terms and limits are at the sole discretion of Diedrich Drill, Inc. and may be changed at any time.

  Authorized Officer of Company               Date

Trade Reference(4 Req'd)

Name Name
Address Address
City City
State     Zip State     Zip
Phone Phone
Fax Fax
Acct# Acct#
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Name Name
Address Address
City City
State     Zip State     Zip
Phone Phone
Fax Fax
Acct# Acct#
Bank:
Name Address
Phone Acct#
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For Diedrich Drill use only
Approved by: Date
Terms: Credit Limit:

   

 

Diedrich Drill, Inc.
5 Fisher St.
LaPorte, IN 46350
Phone (219) 326-7788 Phone (800) 348-8809
Fax (219) 324-5962