Application for Open Account

Please provide us with the following information so we may process your request as quickly as possible.

Name *

Company Name *

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Email *

Phone *

Fax

Address *

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Address Line 2

City

State

Zip Code

How Many Years in Business? *

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References: Please provide at least 2 (or more) references.

REFERENCE #1

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Last

Business Name *

Address *

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Address Line 2

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State

Zip Code

Email *

Phone *

Fax

REFERENCE #2

Name *

First

Last

Business Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Fax

BANK INFORMATION

Bank Name *

Bank Contact Name *

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Last

Bank Phone *

Account Number

Address of Bank *

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Checkboxes *

I understand that my signature below constitutes permission for the bank referenced above to release credit information to Akerly & Childs Inc. upon their request. This information will be kept confidential and will be used for credit rating purposes only.

Signature *

Please type your full name as your signature.

Title *

Date / Time *

Date

Time

Akerly & Childs Inc. 24927 Avenue Tibbitts Ste F, Valencia CA. 91355 Phone (661)702-1909 Fax (661)702-1906

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