Date
Company Name
Mailing Address
Shipping Address
City
State
Zip Code
Telephone #
Type of Business
Type of Organization
Years in Business
Driver's License #
Bank References
Bank Account #
Bank Account Type
Bank Telephone #
Trade References
Supplier
Trade Telephone #
Trade Address
Account #
Name
By clicking the submit button below, the undersigned individual, who is either a principal, a personal guarantor or a sole proprietorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents and authorizes Starvin Marvin's Seafoods or its designee the use of a consumer credit report on the undersigned, from time to time as may be needed. A Fax copy of this authorization shall be valid as original.