Empire Machinery & Supply Corporation
3550 Virginia Beach Blvd. * P.O. Box 27 * Norfolk, Virginia 23501
Phone 757-222-9200 * Fax 757-857-6545 * Toll-Free 1-800-289-6747

PENINSULA DIVISION
711 Howmet Drive * P.O. Box 9388 Briarfield Station * Hampton, Virginia 23670
Phone 757-827-1440 * Fax 757-827-5938

CREDIT APPLICATION

Date
Firm Name

Phone 
Billing Address

Fax 
City State

Zip Code 

 -
Business Type

FED ID # or SSN 

Street Address
Parent Company
Address
As Applicable, List Name(s) and Address(es) of Corporated Officers, Partners, and Owners
Name / Title

Address 
Name / Title

Address 
Name / Title

Address 
Name / Title

Address 
Type of Business
Location

Phone 
How Long
in Business

Number of Employees 
How Long
at Present Location

Annual Sales 
Person Responsible
for Accounts Payables

Net Worth 
Name of Bank

Address 
Account Number

Contact 
Trade References
Name / Title

Phone or Fax
Name / Title

Phone or Fax
Name / Title

Phone or Fax
Name / Title

Phone or Fax

(Please mail Virginia & North Carolina sales tax exemption certificates)
I certify that the above statements are true and correct and authorize Empire Machinery & Supply Corporation to obtain such information as may be required concerning this application.
Signature / Title