BDM MICRO

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					  BDM MICRO                                                         Credit Application
2625 St. Simons
Tustin, Ca. 92782
714-293-3436 (Cel)
714-832-5442
dcomstock@bdmmicro.com
www.bdmmicro.com




    1)   Legal Business Name ____________________________________________________________________________

         Type of Business         ____________________________________                         Years in Business_______________

         Duns #                   ____________________________________                         Estimated Sales: _______________

         Street Address           ____________________________________                         Main Phone Number:___________________________

         P.O. Box Address         ____________________________________                         Main Fax Number:_____________________________

         City:                    ____________________________________                         A/P Contact Name: ____________________________

         State:                   ____________________________________                         A/P Contact Phone/FAX:_________________________

         Zip Code:                ____________________________________

         Country                  ____________________________________

    2)   Federal Taxpayer Identification
         Or Social Security Number (TIN/SS#):________________________

    3)   1099 Info./Legal Status of Business __________Partnership____________Sole Proprietor__________Corporation___________Other

    BANK REFERENCE

         Name of Bank:            ____________________________________________________

         Account Number:          ____________________________________________________

         Address                  ____________________________________________________

         Phone/Fax Number         ____________________________________________________

         Contact                  ____________________________________________________

    TRADE REFERENCES (3 Required)

    1)   Company                  ___________________________________________________________________________

         Contact Name             ___________________________________________________________________________

         Phone Number             ___________________________________________________________________________

         Fax Number               ___________________________________________________________________________

         Email                    ___________________________________________________________________________

    2)   Company                  ___________________________________________________________________________

         Contact Name             ___________________________________________________________________________

         Phone Number             ___________________________________________________________________________

         Fax Number               ___________________________________________________________________________

         Email                    ___________________________________________________________________________

    3)   Company                  ___________________________________________________________________________

         Contact Name             ___________________________________________________________________________

         Phone Number             ___________________________________________________________________________

         Fax Number               __________________________________________________________________________

         Email                    __________________________________________________________________________

                                                   FORM MUST BE COMPLETED OR IT WILL BE RETURNED FOR COMPLETION
                      The above information is for the purpose of obtaining credit and is to my knowledge to be true. I authorize the company to whom
                      this application is made to investigate the reference listed pertaining to our credit and financial information


         Customer     ______________________________________          ________________            _____________________________________
Signature   Date   Print Name

				
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