BusinessIQ

General Information

^Brin Division

Trade Reference Information

^*Reference Name

Reference Account Number

Contact Name

^*Phone Number

^*Contact Email

^*Reference Name

Reference Account Number

Contact Name

^*Phone Number

^*Contact Email

^*Reference Name

Reference Account Number

Contact Name

^*Phone Number

^*Contact Email

Bank Reference Information

^*Bank Name

Bank Account Number

Bank Email Address

Bank Contact Name

Bank Contact Phone Number

Principal / Guarantor Information

^*Principal Type

^*Principal Title

^*Principal First Name

Principal Middle Name

^*Principal Last Name

^*Principal Home Address

^*City

^*State/ Province

^*Zip/Postal

^*Telephone - Home

Telephone - Work

^*Principal Email Address

Principal Social Security Number (SSN)

^*Personal Guarantee Authorization (Y/N)
Yes No

Principal Type

Principal Title

Principal First Name

Principal Middle Name

Principal Last Name

Principal Home Address

City

State/ Province

Zip/Postal

Telephone - Home

Telephone - Work

Principal Email Address

Principal Social Security Number (SSN)

Personal Guarantee

For valuable consideration and in consideration of the extension of credit to the foregoing applicant, the undersigned absolutely and unconditionally guarantees to Brin Glass Company the full and prompt payment when due of any and all indebtedness, obligations and liabilities of the applicant. The undersigned waives presentment, demand for payment, notice of dishonor, notice of nonpayment, and protest of any instrument evidencing the indebtedness. The undersigned further agrees to pay reasonable attorney fees and other cost incurred in collection of this account.

PRINT AGREEMENT

Signature Of Guarantor

Title

Date

Attachments

Please attach documents relevant to the application decision process (i.e., company financials, relevant license information, etc)

Attachment Description

Attachment Location

Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.

Terms and Conditions

^*Signature of Applicant

^*Title

^*Date

PRINT AGREEMENT

I agree to the terms and conditions specified above.

User Verification

Please complete the following by entering the value EXACTLY how it appears(case sensitive)

Why do I have to do this?