CREDIT APPLICATION
FORM

Apply here today for credit on services for your business. Once your application is submitted, we will review and respond as soon as possible. Please note that qualification is up to the discretion of Hampton Concrete Products, Inc. and is not guaranteed. Complete the form below to apply. Mailed copies of this form can be sent to 1435 Pittsburgh Road, Valencia, PA 16059 or faxed to (724)-443-7207.

View a printable pdf version.

Business Name: *

Owner/Manager Full Name: *

Address: *

Email: *

Trade Reference #1

Name:

Address:

Phone Number:

Bank Reference #1

Name:

Address:

Phone Number:

Trade Reference #2

Name:

Address:

Phone Number:

Bank Reference #2

Name:

Address:

Phone Number:

Age of Business: *

D & B Rating: *

Pending Lawsuits: *

Credit Line Request: *

DISCLAIMER

Submission of this application authorizes a check of credit information. We further acknowledge that credit privileges, if granted, may be withdrawn at any time. All statements made herein are true and accurate to the best of our knowledge. We authorize the above company to make any and all inquiries necessary for processing of this credit application. We hereby indemnify the above company and its agents from any liability resulting from their credit survey.