|
Application for Credit
(Please fill out completely) |
|
Billing Information |
Shipping Information
(If Different) |
| Company |
|
Company
|
|
| Contact |
|
Contact |
|
| Address |
|
Address |
|
| Address1 |
|
Address1 |
|
| City |
|
City |
|
| State |
|
Zip |
|
State |
|
Zip |
|
| Phone # |
|
Ext |
|
Phone # |
|
Ext |
|
| Fax # |
|
Fax # |
|
| email |
|
email |
|
|
Tax
Exempt?
Yes
No
If yes, you will need to fill out a Certificate of Resale
(link on the confirmation page) |
Business Type |
|
|
How Many
Years in Business?
|
Own
or lease your building?
Own
Lease |
Is company
less than two (2) years in business?
(If yes Consumer credit report
of principals may be needed to extend credit.)
Yes
No |
Will you
accept COD or Credit Card shipments
while credit is
being processed?
Yes
No |
|
Names & home addresses of principals.
(Must Include Full Name / Title / Phone# / SS#) |
|
Bank References |
Trade References
(3 Required) |
| Bank |
|
Vendor 1 |
|
| Address |
|
Address |
|
| City, St, Zip |
|
City, St, Zip |
|
| Phone # |
|
Phone # |
|
| Fax # |
|
Fax # |
|
| Contact |
|
Account# |
|
| Account# |
|
|
|
Trade References (3 Required - cont.) |
| Vendor 2 |
|
Vendor 3 |
|
| Address |
|
Address |
|
| City, St, Zip |
|
City, St, Zip |
|
| Phone # |
|
Phone # |
|
| Fax # |
|
Fax # |
|
| Account# |
|
Account# |
|
|
The above information is for the purpose of obtaining credit
with FDC Corporation and is warranted to be true. I certify that
I/we have authority to incur liabilities in the name of the
company and hereby authorize the firm to whom the application is
made to make any credit inquiries necessary for approval
pertaining to the Federal Fair Credit Reporting Act.
I represent the I /we are financially able to continue
business, are unaware of any situation that would alter our
financial abilities and have not filed, plan to file or have had
to file any bankruptcy proceedings.
This agreement is subject to credit approval by FDC
Corporation and may be terminated by FDC Corporation at any time
upon proof of poor payment history. |
|
|