Credit ApplicationSchedule FormProfile Sheet APPLICATION FOR CREDIT *NAME OF BUSINESS : *STREET ADDRESS : *MAILING ADDRESS : *CITY/STATE/ZIP : *YEARS IN BUSINESS : *PHONE : FAX : *EMAIL : *ACCOUNT PAYABLE POINT OF CONTACT : PHONE : If Purchase Order is required for pick up, please check this box TYPE OF ORGANIZATION CHECK ONE BELOW Fed ID: Date/State of Incorporation: DUNS/D&B No. CORPORATIONPARTNERSHIPPROPRIETORSHIP *President Name *SS # Vice President Name SS # Secretary Name SS # Treasurer Name SS # Is this company a subsidiary or division of another? YesNo If yes, please complete the parent company information: *NAME OF BUSINESS : *STREET ADDRESS : *MAILING ADDRESS : *CITY/STATE/ZIP : *PHONE : FAX : *EMAIL : *BANK REFERENCES SAVINGSCHECKINGLOANS *BANK NAME : *CONTACT NAME : *ADDRESS : *PHONE : *ACCOUNT NUMBER : *TRADE REFERENCES NAME : ADDRESS : CITY/STATE/ZIP : PHONE : EMAIL : FAX : NAME : ADDRESS : CITY/STATE/ZIP : PHONE : EMAIL : FAX : NAME : ADDRESS : CITY/STATE/ZIP : PHONE : EMAIL : FAX : MSDS/ANALYTICS I hereby certify that the above and attached description is complete and accurate to the best of my knowledge and ability. I certify that all relevant information within the possession of the Generator regarding known or suspected hazards associated with the material described above have been disclosed to Illini Environmental, Inc.. I also certify that the obtained sample (if necessary) is a representative of the material described above and give Illini Environmental, Inc. permission and consent to make amendments and corrections. I will notify Illini Environmental, Inc. of any waste generating process changes and/or changes to the above profiled material prior to shipment. PRINTED NAME DATE COMPANY / TITLE Δ SCHEDULE FORM *Generator Name: *Billing Name: *Site Address: *City/State/Zip: *Job Contact/Phone#: *Email: Notes: *Material: Qty: Haz:YesNo Container: Material: Qty: Haz:YesNo Container: Material: Qty: Haz:YesNo Container: Material: Qty: Haz:YesNo Container: *Requested Date & Time: Dock:YesNo Lift Gate:YesNo Labels:YesNo Manifest Sign:YesNo Fork Lift:YesNo Site Contact: Stinger:YesNo Overpack:YesNo Inside:YesNo Drums on Pallet:YesNo Feet of Hose: Hours of Operation: *Location of Material: *EPA ID#/State ID#: PO#: Additional Description of Material: Additional Waste Streams: MSDS/ANALYTICS I hereby certify that the above and attached description is complete and accurate to the best of my knowledge and ability. I certify that all relevant information within the possession of the Generator regarding known or suspected hazards associated with the material described above have been disclosed to Illini Environmental, Inc.. I also certify that the obtained sample (if necessary) is a representative of the material described above and give Illini Environmental, Inc. permission and consent to make amendments and corrections. I will notify Illini Environmental, Inc. of any waste generating process changes and/or changes to the above profiled material prior to shipment. PRINTED NAME DATE COMPANY / TITLE Δ Error: Contact form not found.
