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Domek Logistics, LLC
265 Exchange Drive, Suite 206
Crystal Lake, IL 60014
Ph: 815.526.3500 Fx: 847.829.3744
CREDIT APPLICATION (page 1 of 3)
COMPANY INFORMATION:
Company Name (EXACT LEGAL NAME):
Address:
City/State/Zip:
Federal Tax ID Number:
Phone: Fax:
Accounts Payable Contact Name:
Accounts Payable Email Address:
Accounts Payable Phone: Company Website:
CHECK ONE:
q Corporation
CHECK ONE:
q Partnership
q Sole
Proprietor
q LLC
Other/Explain: _____________________________________________
CHECK ONE:
Estimated Annual Sales:
Parent Company Info (If different from above):
Name:
Address:
City/State/Zip:
OWNER/SHAREHOLDER INFORMATION: (This section must be completed)
Name:
Title:
% Ownership:
Name:
Title:
q Publicly Held
If Privately-Held, will you supply financial statements on a confidential
basis if needed to establish credit?
Year Established/Incorporated or Years in Business:
Number of Employees: q Privately Held
% Ownership:
q Yes
q No
Domek Logistics, LLC
265 Exchange Drive, Suite 206
Crystal Lake, IL 60014
Ph: 815.526.3500 Fx: 847.829.3744
CREDIT APPLICATION (page 2 of 3)
REFERENCES:
BANK
(Please include operating bank and credit line bank, if different. Attach separate sheet if needed):
Bank Name:
Address:
Loan Officer / Bank Contact:
Phone: Fax:
Email address:
Account Number(s): Credit Line:
TRADE
(Please include vendors with significant credit level activity.):
1) Company Name:
Payment Terms:
Contact:
Address:
Phone: Fax:
2) Company Name:
Payment Terms:
Contact:
Address:
Phone: Fax:
3) Company Name:
Payment Terms:
Contact:
Address:
Phone: Fax:
Domek Logistics, LLC
265 Exchange Drive, Suite 206
Crystal Lake, IL 60014
Ph: 815.526.3500 Fx: 847.829.3744
CREDIT APPLICATION (page 3 of 3)
I understand that the above information is given for the purpose of obtaining credit and hereby authorize
the bank and trade references above to release the requested information. I certify that, to the best of my
knowledge, the above information is complete and accurate as of the date of this application.
COMPANY NAME:
SIGNER’S NAME:
DATE:
TITLE:
AUTHORIZED SIGNATURE: