Application for Open Account

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

Company Name

Address

City

State

Zip

Phone

Fax

Email *

Corporation

LLC

Partnership

Sole Proprietorship

Years in Business

Contact Name

References- Please list Name, Address, Contact, Email, Phone and Fax numbers.

1.) Name

Address

Phone

Fax

2.) Name

Address

Phone

Fax

3.) Name

Address

Phone

Fax

4.) Name

Address

Phone

Fax

Bank Name

Acct #

Address

Phone #

Contact Name

Fax #

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 *

Title *

Date *

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