To: (Trade References _____________________________ Date: __________________

Re: (Account Name)

BE IT KNOWN, the above has applied to us for credit and has listed you as a credit reference. Please be kind enough to provide us the benefit of your credit experience with the account by furnishing the following information:

Highest credit balance: ____________________________________________________

Lowest credit balance: ____________________________________________________

Terms: _________________________________________________________________

Credit furnished to account since: ____________________________________________

Current balance: _________________________________________________________

Credit limit: _____________________________________________________________

Payment history __________________________________________________________

Use the reverse side to note other credit comments. This information shall be held strictly confidential. We are always pleased to reciprocate.

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