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CORPORATE OFFICES
400 Skokie Boulevard
Suite 600
Northbrook, IL 60062
800.872.7370
847.272.7370

CUSTOMER SERVICE FAX
847.272.7713

CREDIT APPLICATION FORM  
Submit our simple on-line form below, OR, if you prefer, click here to download a PDF of our Credit Application Form and fax it to 847.272.7713.

Please complete All Fields. Please use
tab button to move from field to field.
CREDIT APPLICATION
Legal Company Name
Registered DBA Name (If Applicable)
Address
City
State
Zip
FEIN #
Phone
E-mail
Fax
Annual Sales
Company Website
Requested Credit Amount
Line of Business
Year Company Established
Current Ownership Control Year
Organization Type:
Proprietor
C-Corp.
S-Corp.
Partnership

 LLC
LLP
Other:
Have you ever done business with M. Holland Company before? Yes No
If yes, under what name?
 
COMPANY PRINCIPALS/OFFICERS
President
% Ownership
 
CFO
% Ownership
 
Controller
% Ownership
 
TRADE REFERENCES
Vendor 1
Contact
Phone
Fax
Acct#
 
Vendor 2
Contact
Phone
Fax
Acct#
 
Vendor 3
Contact
Phone
Fax
Acct#
 
M. Holland Company's standard terms are
Net 30 days from invoice date.
All other terms must be approved
by M. Holland Company.

If tax-exempt, please provide a copy of the certificate.

FINANCIAL STATEMENTS REQUESTED
FOR ALL LINES OVER $100,000
 
BANK REFERENCES
Bank Reference I
Name
City
State
Acct#
Phone
Fax
Loan Officer
 
Bank Reference II
Name
City
State
Acct#
Phone
Fax
Loan Officer
I hereby certify that the information contained herein is true and correct. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended by M. Holland Company (MHCO). MHCO is hereby authorized to obtain any information it may consider necessary from any source to obtain credit. This signed application is also consent to release information to MHCO in order to evaluate the applicant’s creditworthiness. In consideration of and in order to establish a line of credit, applicant promises to pay for all purchases in accordance with MHCO’s terms and conditions of sale as disclosed upon its invoice. Should a default in payment occur, applicant agrees to pay all reasonable and customary collection and/or legal fees incurred to collect the debt. The customer will reimburse MHCO for any bank fees assessed to MHCO for checks returned by the customer where they have insufficient funds to cover the payment. The undersigned warrants that he/she has authority to execute this open account agreement and to bind said company to the terms and conditions contained in this application. I further acknowledge that if open credit terms are granted, those said terms may be withdrawn at any time.

I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS, AND HEREBY AGREE TO THEM:
Company Name
AUTHORIZED SIGNATURE
(required)
Date

Title
M. Holland Company Sales Representative
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