Company Name: |
___________________________________________ |
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Tax ID #: |
___________________________________________ |
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Date Incorporated: |
___________________________________________ |
|
D-U-N-S #: |
___________________________________________ |
|
PAYDEX Score: |
___________________________________________ |
|
| Amount of Credit requested |
___________________________________________ |
|
| Terms Requested: |
Net 15___-------Net 30____ (please check one) |
|
-------------------------------------------------- |
---------------------------------------------------------------------------- |
|
Shipping address: |
___________________________________________ |
|
|
___________________________________________ |
|
|
___________________________________________ |
|
Shipping contact: |
___________________________________________ |
|
Shipping Phone # |
___________________________________________ |
|
-------------------------------------------------- |
---------------------------------------------------------------------------- |
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Billing address: |
___________________________________________ |
|
|
___________________________________________ |
|
|
___________________________________________ |
|
Billing / Accounts Payable contact: |
___________________________________________ |
|
Billing Phone # |
___________________________________________ |
|
Billing Fax # |
___________________________________________ |
|
-------------------------------------------------- |
---------------------------------------------------------------------------- |
|
Bank Information: |
___________________________________________ |
|
Bank Address: |
___________________________________________ |
|
|
___________________________________________ |
|
Bank Contact: |
___________________________________________ |
|
Bank Contact Phone #: |
___________________________________________ |
|
-------------------------------------------------- |
---------------------------------------------------------------------------- |
|
Business / Trade References: |
|
|
Company: |
___________________________________________ |
|
Address: |
___________________________________________ |
|
Contact: |
___________________________________________ |
|
Phone # |
___________________________________________ |
|
Fax # |
___________________________________________ |
|
-------------------------------------------------- |
---------------------------------------------------------------------------- |
|
Company: |
___________________________________________ |
|
Address: |
___________________________________________ |
|
Contact: |
___________________________________________ |
|
Phone # |
___________________________________________ |
|
Fax # |
___________________________________________ |
|
-------------------------------------------------- |
---------------------------------------------------------------------------- |
|
Company: |
___________________________________________ |
|
Address: |
___________________________________________ |
|
Contact: |
___________________________________________ |
|
Phone # |
___________________________________________ |
|
Fax # |
___________________________________________ |
|
| |
| We authorize Delta Marketing Group Inc., to obtain credit information regarding our company. |
I certify that all the information given is correct. I agree to pay all invoices within the specified payment terms. We agree to pay Delta Marketing Group Inc., liquidated damages in the amount of 1.5% per month for any balance past due. |
Authorized Signature _____________________________ Please Print Name ______________________________ |
Date:__________________________________ |
