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:
___________________
