Click here to download our credit application (PDF) or complete the form below

1. Check One
2. Flint
   Saginaw
   Lansing
   Gaylord
   Lapeer
   Niles
   

Company Information

1. Company Name
2. Date
3. Billing Address
4. City State Zip
5. Shipping Address
6. City State Zip
7. Phone
8. Fax
9. Email

Trade References

1. First Trade.....
2. Name
3. Address
4. City State Zip
5. Phone
6. Fax
7. Second Trade.....
8. Name
9. Address
10. City State Zip
11. Phone
12. Fax
13. Third Trade.....
14. Name
15. Address
16. City State Zip
17. Phone
18. Fax

Bank Reference

1. Bank Name
2. Address
3. City State Zip
4. Phone
5. Fax
6. Account Number
7. Contact person

Company Authorization

1. To our trade and banking references: We have given your name as a trade/banking reference for our company. Please use this authorization from us to provide the requested information to: mid-states bolt & screw co.
2. Company Name
3. Date
4. Your Name & Title (digital signature)

 

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