SOURCETEL
APPLICATION FOR CREDIT |
Company Info |
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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 |
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Primary Bank: |
_______________________________________________________ |
Account Number: |
_______________________________________________________ |
Address: |
_______________________________________________________ |
Phone: |
_____________________________ |
FAX: |
_____________________________ |
Trade References (provide 2)
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Company Name (1): |
_______________________________________________________ |
Address: |
_______________________________________________________ |
Phone: |
_____________________________ |
FAX: |
_____________________________ |
Account #: |
_____________________________ |
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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.
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Signature: |
_______________________________________________________ |
Title: |
_____________________________ |
Date: |
_____________________________ |
Please return by fax to (678) 376-4829,
attention: Credit Department |
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