Company Name:
Mailing Address:
City:
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Zip Code:
Shipping Address:
Telephone:
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Contact Person:
Email Address:
Name of Accounts Payable Representative:
Type of organization: Corp Partnership Proprietor Other
Type of business: City Contractor Engineer Excavator Government Lumber Other Plumber Town Trailer Park Sewer Only Water Co. Water & Sewer Wholesale
Yes: No: Sometimes:
Nearest Kennedy Companies Location: Chantilly, VA Chesapeake, VA Culpeper, VA Fayetteville, NC Hyattsville, MD Kinston, NC Mechanicsville, VA Mt. Laurel, NJ Raleigh, NC
Salesperson: Steve Bradley Jeanette Sullivan Pete Petitt Unknown Other Anthony Dean Rodney Waldron Unknown Other Gene Spittle Unknown Other Victor Putze Bryan Lane Unknown Other Larry Petitt Robert Timko Unknown Other Gene Spittle Michael Mamber Victor Putze Unknown Other Wes Heath Charles Higgins Mark Harrison Unknown Other Bryan Lane David Wilkie Rob Whitten Matthew Rathburn Unknown Other
Owners, Partners, or Officer Name:
Title:
Residence Address:
Home Phone:
Name and location of any other businesses owned:
Insurance Agent:
Address:
Company:
This section is optional but may help us approve your application.
Account Number:
Account Name:
Loan Number:
Loan Name:
Agreement: I hereby acknowledge that I have read the agreement and understand same.
Terms and Conditions: I hereby acknowledge that I have read the Terms and Conditions.
Sign (Type) Name:
