Credit Reference Request
Company Name
Name
First Name
Last Name
Title
Email
example@example.com
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What are your payment terms?
Their average days to pay invoices
Have you received any NSF cheques/payments?
Yes
No
How long have you had a business relationship?
What is their credit limit?
How would you rate their account
Good
1
2
3
4
Poor
5
1 is Good, 5 is Poor
Submit
Should be Empty: