Contact Information

Billing Address

Business Information

Please list the name of the following officers (if not incorporated)

Bank Reference

Business References

Reference 1


Reference 2


Reference 3

Financial Section

Assets


Liabilities


Bank Reference Confirmation Waiver

The following waiver is required to complete Kimray's Credit Application. You must fill out the information below in order to be eligible for credit with Kimray Inc. By completing this form you are giving Kimray Inc. the authorization to obtain a reference from the financial institution associated with your account.

Terms Ageement

By submitting this form you are agreeing that:

I have the authority on behalf of my (our) organization to be bound to the Terms and Conditions of Sale for Kimray Inc., and that I have read and agree to be bound by those terms. The information above has been carefully read by the undersigned and is, to my knowledge, in all respects complete, accurate and truthful. It discloses to Kimray Inc. the true state of my (our) financial condition as of the day of submission. Since that time there has been no material unfavorable change in my (our) financial condition, and if any such change takes place I (we) will give notice.

Optional

Submit Your Application

You must sign your application in order to submit.

To submit your application, type your name below, then sign with your mouse and click "Save Signature".

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