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***CREDIT REFERENCE REQUEST***
Date:	To:
	Fax:
	Re:
THE ABOVE REFERENCED FIRM HAS REQUESTED THAT WE CONTACT YOU AS A CREDIT REFERENCE. ANY INFORMATION YOU CAN GIVE US CONCERNING YOUR CREDIT EXPERIENCE WITH THEM WILL BE HELD IN STRICT CONFIDENCE AND USED ONLY AS AN AID IN ESTABLISHING AN ACCOUNT FOR THE CUSTOMER. PndLEASE COMPLETE THE FOLLOWING QUESTIONNAIRE AND RETURN IT TO US A.S.A.P. THANK YOU FOR YOUR ASSISTANCE.
Sold From:	Last Sale Date:
Current Balance:	Past Due Balance:
Recent High Credit:	Ave Days Past Due:
Payment Trend	Other Information
(  ) Discounts/Prompt Pay	Acct Payment Terms:
(  ) Over 30 Days Pay	(  ) Returned Checks
(  ) Over 60 Days Pay	(  ) Returns Merchandise
(  ) 90 + Days Pay	(  ) Has been Placed for Collection
	Takes Unearned Discounts
IS THIS ACCOUNT SECURED?    (  ) YES    (  )NO IF SO, HOW?_________________________________________________________
PERSONAL GUARANTEE SIGNED?   (  )YES   (  )NO
COMMENTS:________________________________________________________