"*" indicates required fields Date* To* Attention* Phone*FaxEmail* RE: CREDIT REFERENCE REQUEST FOR CUSTOMER NAME:* ACCOUNT #:* The above referenced firm has completed an application for an open credit with MX. Your company has been listed as a credit reference. We would appreciate it if you could please complete this form at your earliest opportunity and return to my attention. All information given will be held strictly confidential. There is an Order Pending so your immediate response would be greatly appreciated. Date Account Open: Payment Terms: Credit Line: Last Sale: High Credit: Balance: Payment Record:* Prompt Days Late Discounts Account Status:* Current 30 Days 60 Days + Overall Rating of this Customer:*Signature*Date* Thank you for your cooperation and assistance. Please do not hesitate to contact me with any questions or additional comments. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.