Legal Company Name *

Company Billing Address *

Company Mailing Address

Contact First Name *

Contact Last Name *

Contact Email *

Contact Phone

Accounts Payable First Name *

Accounts Payable Last Name *

AP Email *

AP Phone

Company Website

Preferred Terms

Net 30
Discount Terms

Credit Limit Desired

Annual Sales

Special Shipping or Billing Requirements

Tax Identification Number *

Resale #

DUNS #

Business License #

Bank Information

Bank Name *

Bank Address

Phone *

Email

Bank Officer Name *

Account Number

Trade References

Company 1

Company Address

Contact Name

Phone

Email

Company 2

Company Address

Contact Name

Phone

Email

Terms of Sale

Invoices are due Net 30 days from the date of the invoice to customers with approved credit, unless otherwise specified on the invoice, and in accordance with all other terms and conditions expressed in the invoice. Any invoice not paid per its terms will be designated as a "Past Due Account," which can cause delivery or shipment to be withheld on any new or outstanding orders. Past Due Accounts may be placed on COD. Past due invoices will be subject to a 1.5% interest fee per month. Credit card payments are accepted without a discount or surcharge when paid within 10 days of Invoice Date. A 2% credit card surcharge will be added to any invoices paid after that date. Buyer authorizes Seller to request credit related information from any source, including trade references, bank references and/or credit reporting agencies or bureaus and further hereby permit dissemination of credit information about Buyer from inquiring sources and releases Seller from any liability which may result there from. The undersigned is duly authorized to execute this Application on behalf of Buyer. Everything stated in the foregoing Application is true and correct. Thank you for your business. We appreciate the opportunity to be of service!

Bank Information

Trade References

Terms of Sale

Thank you for applying for credit terms, one of our team will get back in touch with you soon.

Thank you for applying for credit terms, one of our team will get back in touch with you soon.

Sylvania 58936 400T4/CL/120V (EHR) Lamp

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