Applicant (Business or Corporate Name):
Business Street Address:
City:
State:	Zip:
Billing Address: (if different than above)
City:
State:	Zip:
Business Phone:
Business Fax:
Year Established:
Number of Employees:
Estimated Monthly Purchases:
Resale Permit or Sales Tax Number:
	(Please mail or fax a hard copy of certificate to Logan at the address/fax number at the bottom of this page.)
My company is engaged in the business of:
Other businesses operated by owner(s):
Type of Business:	Sole Proprietor Partnership Corporation
FEIN Number:
Business Building is:	Owned Rented
If Rented, please complete the following:
Landlord Name:
Landlord Address:
Landlord Phone:
Owner(s) (If applicant is a sole proprietorship or partnership) or Officers (If a corporation)
Name:
Title:
Home Address:
City:
State:	Zip:
Home Phone:
Name:
Title:
Home Address:
City:
State:	Zip:
Home Phone:
Name:
Title:
Home Address:
City:
State:	Zip:
Home Phone:
Please provide information on additional principals in Comments box below if necessary.
Bank or Savings & Loan Association
Name:
Branch Address:
Account #:
Type of Account:
Phone Number:
Fax Number:
Name:
Branch Address:
Account #:
Type of Account:
Phone Number:
Fax Number:
Please provide additional information in Comments box below if necessary.
Applicant's Principal Suppliers Please provide at least three supplier references. Provide additional information in Comments box below if necessary.
Supplier Name:
Address:
Phone:
Fax Number:
Supplier Name:
Address:
Phone:
Fax Number:
Supplier Name:
Address:
Phone:
Fax Number:
HAS APPLICANT OR ANY OF ITS PRINCIPALS EVER FILED A VOLUNTARY PETITION IN BANKRUPTCY? YES NO (If yes, please explain in Comments box below, or on a separate sheet of paper and fax it with your application.)
HAS A TAX LIEN OR CIVIL SUIT BEEN FILED AGAINST APPLICANT OR ANY PRINCIPAL WITHIN THE LAST 6 YEARS? YES NO (If yes, please explain in Comments box below or on a separate sheet of paper and fax it with your application.)
Additional Comments:
Individual supplying information:
Name:
Email:
_____________________________________________ Signature of Applicant (to be used if faxing) _____________________________________________ Printed Name of Applicant (to be used if faxing)

Logan Corporation
PO Box 58, Huntington, WV 25706-0058
Phone: (304) 526-4700 / Fax: (304) 526-4730