Credit and Bank References - PDF by xke58994


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									                                                   Print Form            YOU CAN NOT SAVE THE INFORMATION CREATED IN THIS FORM!
                                                                         PLEASE, PRINT IT AND FAX OR MAIL TO LASERCYCLE!

INSTRUCTIONS: Complete this form in your Acrobat Reader. Print it. Sign, date, and mail or fax it back to LaserCycle at:
                                   8208 Nieman Road, Lenexa, Kansas 66214
                                   Fax Number: 913-894-1212
Please call with questions: 913-894-7470 or 800-219-9204. Email:
                                                                                 Today's Date

Address                                                                          How did you find us?

City                                                                             DBA Name

State/Province                  Zip/Postal Code                                  Phone Number

County                                                                           Fax Number
                                                                              Required for
Contact Name                                                                               Email Address

Form of Ownership                Proprietorship                  Partnership                        Corporation                    Non-Profit

Sales Tax Number                                                      State                 FID #                        State of Incorporation

Credit Limit Requested                                                Year Business Started                       No. of Employees

Principal Owner or Officers of Company (Include Titles):
Principal/Officer #1:                                                                                  Title
Principal/Officer #2:                                                                                  Title

Accounts Payable Contact                                                                               Phone Number
        Accounts Payable Email

Principal Bank                                                                                                 Account Number

Address                                                               City                                                 State          Zip Code

Contact Name                                                          Phone Number                                  Fax Number


Company                                                 Company                                                   Company

Address                                                 Address                                                   Address

City                                                    City                                                      City

State                   Zip Code                        State                    Zip Code                         State                   Zip Code

Phone Number                                            Phone Number                                              Phone Number

Fax Number                                              Fax Number                                                Fax Number

Account Number                                          Account Number                                            Account Number

Applicant agrees to pay any collection costs incurred to collect the amount balance, including reasonable attorney's fees. Applicant also agrees to pay 1.5% per
month service charge for accounts over 30 days old. The signee as an inducement to grant credit warrants that the information submitted is true and correct.
LaserCycle is authorized to investigate the credit and bank references listed above. Application will not be processed without signature.

Owner/Partner/President Signature (Please print application, sign and return via fax or mail.)                                               Date

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