IceMeltMall.Com Credit Form
(This is a print only Form - Print and Fax to 815-469-2960)
Date of Application __________
Name of Business ____________________________________
Address ____________________________________________
City ____________________State ___________________ Zip _____________
Telephone __________________________ Fax __________________
E-Mail Address ______________________
Name of Buyer ________________________ Title _______________
Major Creditors
Name _________________________________________
Address _________________________City_____________________State_____Zip_______
Phone _________________________
Contact person ____________________
.................................................................................................
Name _________________________________________
Address _________________________City_____________________State_____Zip_______
Phone _________________________
Contact person ____________________
.................................................................................................
Name _________________________________________
Address _________________________City_____________________State_____Zip_______
Phone _________________________
Contact person ____________________
.................................................................................................
Name of Bank ___________________________________ Account # ______________
Address _________________________City_____________________State_____Zip_______
Phone _________________________ Fax ________________________
Contact person ____________________
Signature_________________________ Date__________
Please print this form and Fax or mail to:
Ice
Melt Mall
10717 Ashford Ave
Frankfort, IL 60423
Fax# 815-469-2960