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CREDIT APPLICATION (FORM A)

CREDIT APPLICATION (FORM A)

 

 

We are pleased you have selected _________________________ Inc.  Below is some basic information we need in order to establish your account.  Please complete this form and return it to _________________________ Inc., attention new accounts.

 

Company Name:  _________________________________________________

Contact:  ___________________________________________

Billing Address:  _______________________________________________________

City:  ________________________ State:  _____________ Zip Code:  ____________

Shipping Address:  ______________________________________________________

City:  ________________________ State:  _____________ Zip Code:  ____________

Phone:  _________________________ FAX:  __________________________

E-mail:  _____________________________

 

Type of Business:  ____________________________ In Business Since:  __________

Form of Business:  [   ] Corporation  [   ] LLC  [   ] Partnership  [   ] Sole Proprietor

Is a Purchase Order required for the work you will have done?  _________

Name of individual(s) with authorization:  ____________________________________

If it is to be a blanket PO, please list the number and expiration date.

Number ____________________                                              Expiration Date ________________

To whose attention should invoices be sent?  __________________________________

Is your work taxable?  ____  If not, please attach signed certificate and list your tax exempt or resellers number:  ____________________________________________

If you which to pay by credit card, please provide information below:

VISA Card Number __________________________________ Exp. Date __________

MasterCard Number __________________________________ Exp. Date __________

American Express Card Number _________________________ Exp. Date _________

 

Bank References (please list name and address of local banks):

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

 

Trade References (Please list name, address, phone number, and account number of three references.  Do not list credit cards.)

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

 

Our terms are net 30 days.  Accounts not paid in this time frame will be charged 1.5% interest rate per month and future orders will be on a C.O.D. basis until the account is current.  Should collection or legal action be required to collect past dues, said fees will be added to your account. 

 

Print Name:  ___________________________ Title:  __________________________

Signed by:  _______________________________ Date:  ___________________



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