FAX Credit Application Form
Please print out this form, fill out completely and fax to IMTEK at:
(770) 667-8683.
Name_____________________________________________ Title_____________________________________
Company__________________________________________ Address___________________________________
City_____________________________________________ State_____________________________________ Zip______________________________________________ Country___________________________________ Phone____________________________________________ FAX_______________________________________
E-mail___________________________________________
PRINCIPALS (if corporation, list officers, if partnership, list partners)
1. Name______________________________________ Title__________________________________________
Home Address______________________________ City___________________________________________
State_____________________________________ Zip____________________________________________
Country___________________________________ Phone__________________________________________
---------
2. Name______________________________________ Title__________________________________________
Home Address______________________________ City___________________________________________
State_____________________________________ Zip____________________________________________
Country___________________________________ Phone__________________________________________
---------
3. Name______________________________________ Title__________________________________________
Home Address______________________________ City___________________________________________
State_____________________________________ Zip____________________________________________
Country___________________________________ Phone__________________________________________
SALES TAX STATUS (Please check one)
Not Tax Exempt____ Tax Exempt ____ Tax Exempt Number__________________
BANK REFERENCE
Bank Officer__________________________________ Bank Name_________________________________________
Address_______________________________________ City______________________________________________
State_________________________________________ Zip_______________________________________________
Country_______________________________________ Phone_____________________________________________
Account #_____________________________________
TRADE REFERENCES
1. Contact Name_________________________________________________ Company______________________________________________________
Address______________________________________________________
City_________________________________________________________
State________________________________________________________
Zip_________________________________________________________
Country______________________________________________________
Phone________________________________________________________
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2. Contact Name_________________________________________________ Company______________________________________________________
Address______________________________________________________
City_________________________________________________________
State________________________________________________________
Zip_________________________________________________________
Country______________________________________________________
Phone________________________________________________________
----------
3. Contact Name_________________________________________________ Company______________________________________________________
Address______________________________________________________
City_________________________________________________________
State________________________________________________________
Zip_________________________________________________________
Country______________________________________________________
Phone________________________________________________________
BUSINESS INFORMATION
Individual ____ Partnership ____ Corporation ____
Type of Business______________________________ Number of Employees__________________________
Years in Business_____________________________ Annual Sales $_______________________________
D+B Listed? Yes____ No____ Amount of Credit Requested $ ______________________
BY COMPLETING THIS APPLICATION FOR CREDIT, THE APPLICANT:
1. Attests financial responsibility, ability and willingness to pay all invoices
in accordance with the following terms: 2% 10; Net, 30 days, service charges will be
paid at the rate of 1.5% (18% annual rate) on all balances over 30 days.
2. Hereby Authorizes IMTEK ENVIRONMENTAL CORP. to investigate
the references listed pertaining to the applicant's credit and financial responsibility and
obtain additional information by securing data from a credit reporting agency.
3. Hereby Agrees that should it become necessary to assign the applicant's
account to a licensed collection agency or atttorney for legal action, all subsequent
collection charges and legal fees shall be paid by the applicant.
4. Hereby Authorizes the seller, its successors and assigns, by the seller's
designated attorney to waive the issuance of process and confess judgment against the
applicant for the entire unpaid balance of applicant's account together with all costs
applicable to such action.
5. Certifies and Warrants that the information given in this application is true and
correct and is given for the purpose of obtaining credit.
Applicant Name__________________________________ Position____________________________________
Date________________
Applicant Name___________________________________ Position____________________________________ Date________________
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FAX Credit Application Form
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