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