| Company Information |
|---|
| Name of Company: | * |
| Phone #: | * |
| Fax #: | * |
| Website: | * |
| Billing Address |
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| Address 1: | * |
| Address 2: | |
| City: | * |
| Country: | * |
| State: | * |
| County: | * |
| Zip: | * |
| Province: | * |
| Postal Code: | * |
| A/P Contact |
|---|
| Name: | * |
| Email: | * |
| Purchasing Agent |
|---|
| Name: | * |
| Email: | * |
| CFO |
|---|
| Name: | * |
| Email: | * |
| More Company Info |
|---|
| Date of Incorporation: | * |
| State of Incorporation: | * |
| DUN & Bradstreet #: | * |
| Sic Code #: | |
| Yrs. in Business: | * |
Unfortunately, we are unable to offer you a line of credit if your business is less that 3 years old. Continue on to our Online Store for credit card transactions.
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| Customer Type: |
* |
| Company Type: |
Public
Private
* |
| Ticker Symbol: | * |
| Tax Exempt #: | * |
| Resale Certificate #: | * |
| Credit Line Requested: |
* |
| Credit Line Requested: |
* |
| Credit Line Requested: |
* |
| Credit Line Requested: |
* |
| Full Name of Officer, Owner, or Partner |
|---|
| Name: | * |
| Position / Title: | * |
| Social Security #: | * |
| Personal Address |
| Street: | * |
| City: | * |
| State: | * |
| Zip: | * |
| Attach Financials: | * |
| Bank Reference |
|---|
| Bank Name: | * |
| Contact Name: | * |
| Phone #: | * |
| Business References (2) |
|---|
 OR  |
|
| Attach References: | * |
| Reference 1: Company: | * |
| Acct#: | * |
| Street: | * |
| City: | * |
| State: | * |
| Zip: | * |
| Phone #: | * |
| Contact Name: | * |
|
| Reference 2: Company: | * |
| Acct#: | * |
| Street: | * |
| City: | * |
| State: | * |
| Zip: | * |
| Phone #: | * |
| Contact Name: | * |
| Terms Agreement |
|---|
| Agree to Terms & Conditions: | * |
You are authorized to obtain any information you may require regarding the statements above. This application shall remain the property of the company.
All statements made on this application are made for the purpose of obtaining credit. I understand that, in considering this application for credit,
you will rely upon the statements contained herein. I have reviewed the information contained in this application, and I affirm that the foregoing
statements are accurate and complete, and are made to induce Amdex Computer, Inc. to grant the applicant credit. I warrant that no information
has been concealed or withheld which may be material to a proper consideration by you of this application. Applicants aggreement attests financial responsibility,
ability and willingness to pay our invoices with the terms as explained.
Close
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| Your Name: | * |
| Your Title: | * |
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