"Secure Storage When and Where You Want It" 303.558.6645

Credit Application

Brekke Storage
105 3rd Ave
Longmont, CO 80501
303-776-2610

Customer/Company Information:

Name:_______________________________________ Contact Name:______________________________ Title:__________________________

Address:_____________________________________ City:_____________________________ State:______________ Zip:___________________

Phone:________________________________ Fax:___________________________ Federal Tax ID#:_______________________________________

A/P Contact:________________________________ Phone:__________________________ Fax:_____________________________

PO Required: Yes No

Trade Reference:

Reference #1

Company Name:__________________________________________________ Contact Name:___________________________________________

Address:___________________________________________________________________________________________________________________

Phone:___________________________________ Fax:_____________________________ Account #:________________________________

Reference #2

Company Name:__________________________________________________ Contact Name:___________________________________________

Address:___________________________________________________________________________________________________________________

Phone:___________________________________ Fax:_____________________________ Account #:________________________________

Reference #3

Company Name:__________________________________________________ Contact Name:___________________________________________

Address:___________________________________________________________________________________________________________________

Phone:___________________________________ Fax:_____________________________ Account #:________________________________

Bank Reference

Name:___________________________________________ Contact Name:____________________________ Account#:________________________

Address:_____________________________________________________________________ Phone:___________________ Fax:_________________

Insurance Information

Name:________________________________________________ Agent’s Name:______________________________ Policy #:___________________

Address:____________________________________________________________________________________________________________________

Phone:____________________________________ Fax:___________________________________

My signature below hereby give authorization to Brekke Storage to do a trade reference credit check, bank reference, credit history on this company:

Signature_____________________________________________________________ Print Name:___________________________________________

Personal Guarantee Yes No Title/Date:____________________________________________

To hvae a credit card billed monthly:

Sign Here (as it appears on the card)_________________________________________________ Credit Card Type Visa M/C

Name on Card:_________________________________________________ Number:_____________________________________________________

Expiration Date:__________________ 3 Didgit Security Code:_________ (code is located on the back of the card after the account number)

Print and Fax to 303-776-2610