Credit Application Form

Document Sample
Credit Application Form Powered By Docstoc
					                                                                          Please complete th
                                                                                e-mail:

NAME:                                                                 DATE:

BILLING ADDRESS:                                                      SHIPPING ADDRESS:




TELEPHONE #:                                                          FAX #:

CHECK ONE: ( ) CORPORATION         ( ) PARTNERSHIP         ( ) SINGLE PROPRIETOR

TAX ID NUMBER                                                         EXPORT TAX ID NUMBER
                                                                      (International Shipments o
NAME OF COMPANY OFFICERS OR OWNER(S):

           PRESIDENT                                                  S/S#

           VICE PRESIDENT                                             S/S#

           TREASURER                                                  S/S#


PURCHASING CONTACT:                                                   Phone #:
ACCOUNT PAYABLE CONTACT:                                              Phone #
                   TRADE REFERENCES: Give complete name, address with zip code, phone, fax number an



Name                                                                  Phone #

Address:                                                              Fax #

                                                                      Account #




Name                                                                  Phone #

Address:                                                              Fax #
                                                                           Account #




Name                                                                       Phone #

Address:                                                                   Fax #

                                                                           Account #

BANK REFERENCE: Give Complete Name, Address, Phone Number, Person to Contact and Back Account Number.



Bank Name:                                                                 Phone #:

Address:

Account #                                                                  Person to Contact

D & B Number



SIGNATURE:                                                                 TITLE
       By signing this application, you are giving Adroit Medical Systems authorization to inquire about
                                    Credit Application
Please complete this form and fax to 865.458.0880
            cstoneadroit@aol.com              865-458-8600



PING ADDRESS:




 OPRIETOR

ORT TAX ID NUMBER
 national Shipments only)




code, phone, fax number and account number.
Back Account Number.




rization to inquire about your credit and bank references.
    Adroit Medical Systems                                                                          PH: 800-267-6077
 1146 Carding Machine Road                                                                          FX: 865-458-0880
    Loudon, TN 37774                                                                                http://adroitmedical.com




                              CREDIT CARD - Credit Application - ONLY
                         Please complete this form and fax to Cindy Stone @ 865-458-0880
                             e-mail: cstoneadroit@aol.com, Tel 865-458-8600 ext. 102


NAME:                                                              DATE:



BILLING ADDRESS:                                                   SHIPPING ADDRESS:




TELEPHONE #:                                                       FAX #:



CHECK ONE: ( ) CORPORATION         ( ) PARTNERSHIP   ( ) SINGLE PROPRIETOR



TAX ID NUMBER                                                      EXPORT TAX ID NUMBER
                                                                   (International Shipments only)

NAME OF COMPANY OFFICERS OR OWNER(S):


                  PRESIDENT                                        S/S#

                  VICE PRESIDENT                                   S/S#

                  TREASURER                                        S/S#




PURCHASING CONTACT:

E-MAIL ADDRESS:



ACCOUNT PAYABLE CONTACT:

E-MAIL ADDRESS:




SIGNATURE                                                          TITLE




    Page 5 of 6                                                                                      HW/Forms/3990f35c-d6ce-48b6-98e8-282409b6a56d.xls
Dear Customer:

This file includes two credit applications that you may use.
If you are applying for terms, i.e. Net 30 Days, please use TAB 1.
If you are using a Credit Card or COD for payment, please use TAB 2.

Please fax or e-mail your credit application with your Re-Sales / Exemption Certificate.


Thank you,

Adroit Medical Systems
800-267-6077
Fax 865-458-0880

				
DOCUMENT INFO
Description: Credit Application Form document sample