Please fill out form completely and carefully. ADDRESS Name: Title: Company: Address: City: State: Zip: Country: Phone: FAX: Email: _____________________________________________________________________ PRINCIPALS (if corporation, list officers, if partnership, list partners) 1. Name: Title: Home Address: City: State: Zip: Country: Phone: _____________________________________________________________________ 2. Name: Title: Home Address: City: State: Zip: Country: Phone: _____________________________________________________________________ 3. Name: Title: Home Address: City: State: Zip: Country: Phone: _____________________________________________________________________ SALES TAX STATUSNot Tax Exempt Tax Exempt --- Exempt # _____________________________________________________________________ BANK REFERENCE Bank Officer: Bank Name: Address: City: State: Zip: Country: Phone: Account #: _____________________________________________________________________ TRADE REFERENCES 1. Contact Name: Company: Address: City: State: Zip: Country: Phone: _____________________________________________________________________ 2. Contact Name Company Address City State Zip Country Phone _____________________________________________________________________ 3. Contact Name Company Address City State Zip Country Phone _____________________________________________________________________ BUSINESS INFORMATION Individual Partnership Corporation Type of Business Number of Employees Years in Business Annual Sales $ D+B Listed? Yes No Amount of Credit Requested $ _____________________________________________________________________ BY COMPLETING THIS APPLICATION FOR CREDIT, THE APPLICANT: 1. Attests financial responsibility, ability and willingness to pay all invoices in accordance with the following terms: 2% 30; Net, 30 days, service charges will be paid at the rate of 1.5% (18% annual rate) on all balances over 30 days. 2. Hereby Authorizes IMTEK. to investigate the references listed pertaining to the applicant's credit and financial responsibility and obtain additional information by securing data from a credit reporting agency. 3. Hereby Agrees that should it become necessary to assign the applicant's account to a licensed collection agency or atttorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant. 4. Hereby Authorizes the seller, its successors and assigns, by the seller's designated attorney to waive the issuance of process and confess judgment against the applicant for the entire unpaid balance of applicant's account together with all costs applicable to such action. 5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit. Applicant Name: Position: Date: Applicant Name: Position: Date:
Name: Title: Company: Address: City: State: Zip: Country: Phone: FAX: Email:
_____________________________________________________________________
PRINCIPALS (if corporation, list officers, if partnership, list partners)
1.
2.
3.
SALES TAX STATUSNot Tax Exempt Tax Exempt --- Exempt # _____________________________________________________________________ BANK REFERENCE Bank Officer: Bank Name: Address: City: State: Zip: Country: Phone: Account #: _____________________________________________________________________ TRADE REFERENCES 1. Contact Name: Company: Address: City: State: Zip: Country: Phone: _____________________________________________________________________ 2. Contact Name Company Address City State Zip Country Phone _____________________________________________________________________ 3. Contact Name Company Address City State Zip Country Phone _____________________________________________________________________ BUSINESS INFORMATION Individual Partnership Corporation Type of Business Number of Employees Years in Business Annual Sales $ D+B Listed? Yes No Amount of Credit Requested $ _____________________________________________________________________ BY COMPLETING THIS APPLICATION FOR CREDIT, THE APPLICANT: 1. Attests financial responsibility, ability and willingness to pay all invoices in accordance with the following terms: 2% 30; Net, 30 days, service charges will be paid at the rate of 1.5% (18% annual rate) on all balances over 30 days. 2. Hereby Authorizes IMTEK. to investigate the references listed pertaining to the applicant's credit and financial responsibility and obtain additional information by securing data from a credit reporting agency. 3. Hereby Agrees that should it become necessary to assign the applicant's account to a licensed collection agency or atttorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant. 4. Hereby Authorizes the seller, its successors and assigns, by the seller's designated attorney to waive the issuance of process and confess judgment against the applicant for the entire unpaid balance of applicant's account together with all costs applicable to such action. 5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit. Applicant Name: Position: Date: Applicant Name: Position: Date:
Not Tax Exempt Tax Exempt --- Exempt #
BANK REFERENCE
TRADE REFERENCES
BUSINESS INFORMATION
Individual Partnership Corporation
BY COMPLETING THIS APPLICATION FOR CREDIT, THE APPLICANT: 1. Attests financial responsibility, ability and willingness to pay all invoices in accordance with the following terms: 2% 30; Net, 30 days, service charges will be paid at the rate of 1.5% (18% annual rate) on all balances over 30 days. 2. Hereby Authorizes IMTEK. to investigate the references listed pertaining to the applicant's credit and financial responsibility and obtain additional information by securing data from a credit reporting agency. 3. Hereby Agrees that should it become necessary to assign the applicant's account to a licensed collection agency or atttorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant. 4. Hereby Authorizes the seller, its successors and assigns, by the seller's designated attorney to waive the issuance of process and confess judgment against the applicant for the entire unpaid balance of applicant's account together with all costs applicable to such action. 5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit. Applicant Name: Position: Date: Applicant Name: Position: Date:
1. Attests financial responsibility, ability and willingness to pay all invoices in accordance with the following terms: 2% 30; Net, 30 days, service charges will be paid at the rate of 1.5% (18% annual rate) on all balances over 30 days. 2. Hereby Authorizes IMTEK. to investigate the references listed pertaining to the applicant's credit and financial responsibility and obtain additional information by securing data from a credit reporting agency. 3. Hereby Agrees that should it become necessary to assign the applicant's account to a licensed collection agency or atttorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant. 4. Hereby Authorizes the seller, its successors and assigns, by the seller's designated attorney to waive the issuance of process and confess judgment against the applicant for the entire unpaid balance of applicant's account together with all costs applicable to such action. 5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit. Applicant Name: Position: Date: Applicant Name: Position: Date:
2. Hereby Authorizes IMTEK. to investigate the references listed pertaining to the applicant's credit and financial responsibility and obtain additional information by securing data from a credit reporting agency. 3. Hereby Agrees that should it become necessary to assign the applicant's account to a licensed collection agency or atttorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant. 4. Hereby Authorizes the seller, its successors and assigns, by the seller's designated attorney to waive the issuance of process and confess judgment against the applicant for the entire unpaid balance of applicant's account together with all costs applicable to such action. 5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit. Applicant Name: Position: Date: Applicant Name: Position: Date:
3. Hereby Agrees that should it become necessary to assign the applicant's account to a licensed collection agency or atttorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant. 4. Hereby Authorizes the seller, its successors and assigns, by the seller's designated attorney to waive the issuance of process and confess judgment against the applicant for the entire unpaid balance of applicant's account together with all costs applicable to such action. 5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit. Applicant Name: Position: Date: Applicant Name: Position: Date:
4. Hereby Authorizes the seller, its successors and assigns, by the seller's designated attorney to waive the issuance of process and confess judgment against the applicant for the entire unpaid balance of applicant's account together with all costs applicable to such action. 5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit.
5. Certifies and Warrants that the information given in this application is true and correct and is given for the purpose of obtaining credit.
