Company
Name: |
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Tax ID
#: |
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Date Incorporated:
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D-U-N-S
#: |
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PAYDEX
Score: |
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Terms
Requested: |
Net 15___
Net 30____ (please check one) |
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Shipping
address: |
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Shipping
contact: |
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Shipping
Phone # |
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Billing
address: |
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Billing
/ Accounts Payable contact: |
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Billing
Phone # |
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Billing
Fax # |
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Bank
Information: |
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Bank Address:
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Bank Contact:
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Bank Contact
Phone #: |
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Business
/ Trade References: |
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Company:
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Address:
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Contact:
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Phone #
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Fax # |
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Company:
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Address:
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Contact:
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Phone #
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Fax # |
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Company:
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Address:
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Contact:
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Phone #
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Fax # |
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We
authorize 4-MidRangeSystems.com, to obtain credit information
regarding our company. |
I
certify that all the information given is correct. I agree to
pay all invoices within the specified payment terms. We agree
to pay 4-MidRangeSystems.com, liquidated damages in the amount
of 1.5% per month for any balance past due. |
Authorized
Signature _____________________________ Please Print Name ____________________________ |
| Date:_______________________________ |
