SOURCETEL APPLICATION FOR CREDIT

Company Info

  
Business Name:

_______________________________________________________
Bill To Address:  _______________________________________________________
City:  _______________________________________________________
State:  _____________________________
Zip:  ______________
Country: _____________________________
Phone Number:  _____________________________
FAX: _____________________________
President or CEO: _______________________________________________________
Credit Line Desired Per Month (USD) $: _____________________________
Dun and Bradstreet #: _____________________________
 

Bank Reference

  

Primary Bank:

 _______________________________________________________

Account Number:

 _______________________________________________________
Address: _______________________________________________________
Phone: _____________________________
FAX: _____________________________
 

Trade References (provide 2)

 

  
Company Name (1): _______________________________________________________
Address: _______________________________________________________
Phone: _____________________________
FAX: _____________________________
Account #: _____________________________
   
Company Name (2): _______________________________________________________
Address: _______________________________________________________
Phone: _____________________________
FAX: _____________________________
Account #: _____________________________
 

Tax exempt? (Please FAX tax exemption certificate with application)

I authorize the release of any and all Credit / Banking information as required by and to Sourcetel Supply, LLC. By signing this document my organization accepts the Terms and Conditions for Orders from Sourcetel Supply, LLC.

 
Signature: _______________________________________________________
Title: _____________________________
Date: _____________________________

 

Please return by fax to (678) 376-4829, attention: Credit Department