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Superior Clay Corporation
PO Box 352
Uhrichsville, Ohio 44683
800 848 6166 or 740 922 4122 (fax 740 922 6626)
Email Superior Clay

Name of company_________________________________________________ Address_________________________________________________________ ________________________________________________________________ Phone______________________________FAX_________________________ Company is a Corporation______, Partnership_______, or Proprietorship_____ Tax ID number___________________ Number of years in business__________ Company officers________________________ _________________________ _______________________________________ _________________________ Bank name________________________ Officer's name __________________ Bank address_____________________________ Phone__________________ Bank account numbers_____________________ _________________________ Trade references: 1. _________________________________ ____________________________ 2. _________________________________ ____________________________ 3. _________________________________ ____________________________ Are there suits for debts owed or unsatisfied judgements against the company or has the company or any entity controlled by the company been declared bankrupt within the last ten years?_________ If yes, explain _________________________________________________________________ _________________________________________________________________ Authorized Signor_____________________________ Date__________________ Title___________________________ Office use only Approved_______________________ Limit __________________ Date ________ Not approved____________________ Reason_________________ Date ________

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