Credit Form

Call Toll Free 866-586-3872

Call Toll Free 866.586.3872 Fax 702.294.5566 International 001.702.294.5566 Email: Sales Email: Technical Support

Home

Line Card

Credit Application Form

IN THE EVENT THAT YOUR COMPANY HAS A CREDIT REFERENCE FORM PLEASE INCLUDE AND FAX WITH SIGNATURE AT THE BOTTOM OF THIS FORM TO

702-294-5133

JUNE COMPANY CREDIT APPLICATION FOR NET 30 ACCOUNT

COMPANY_________________________________________________________________

FEDERAL ID #______________________________________

BILLING ADDRESS_____________________________________________________

CITY____________________________ STATE_________________ ZIP___________

PHONE (_____)_____________________ FAX_(_____)_________________________

YEAR ESTABLISHED ____________________________________

D&B #______________________

TYPE OF ENTITY: CORPORATION _____ PARTNERSHIP_____

SOLE PROPRIETOR ________

TAX FILING STATUS: EXEMPT _______(PLEASE PROVIDE COPY OF TAX EXEMPTION FORM) TAXABLE __________

A/P CONTACT NAME ____________________________

A/P PHONE #_______________________EXT_________

BANK REFERENCE NAME____________ ____________________________

CONTACT NAME ______________________________________

PHONE # (_____)_______________________FAX (____)_________________________

ACCOUNT # ____________________________

TRADE REFERENCES:

COMPANY ____________________________ CONTACT___________________________

PHONE (_____)________________________ FAX(____)____________________________

ACCOUNT.# ____________________________

COMPANY ____________________________ CONTACT___________________________

PHONE (_____)________________________ FAX(____)____________________________

ACCOUNT.# ____________________________

COMPANY ____________________________ CONTACT___________________________

PHONE (_____)________________________ FAX(____)____________________________

ACCOUNT.# ____________________________

I, _________________________ the undersigned, being a duly authorized representative of

_______________________do hereby apply for net 30 day credit from June Company. I/We agree to honor the payment terms of net 30 days from invoice date. I also understand if invoices are not paid within the net 30 days from the invoice date, I/we also agree, to pay a finance charge of 2% monthly on the invoice balance and all collection charges, attorney’s fees and court costs where applicable.

SIGNATURE____________________________TITLE__________________DATE_________