Credit Application

Credit Application
Date*

MonthDayYear
Company Name*
Contact Name*

First NameLast Name
Your Title / Position*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Fax Number
Email*
Company Tax ID / Principal SSN*
Year Business was Established*
Type of Enterprise*
* If you chose Corporation, what State / Province is the Corporation registered in?

Street Address

Street Address Line 2

City

Postal / Zip Code
Company Type
Company Type (Other)
Brief Company Description*
Billing Information
Is your billing address the same as your contact information?

Yes (Please skip the next section)No (Please fill out the section below)
Billing Contact Name

First NameLast Name
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Phone Number
Billing Fax Number
Billing Email
Is a Purchase Order Number Required?*

YesNo
Tax Exempt / Resale Certificate

***We have to collect tax in many states. Please include any tax exempt certificates you may have when sending back this form so we do not need to charge you tax.
Cancelof
Trade Reference 1
Company Name*
Contact Name*

First NameLast Name
Title / Position*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Fax Number
Email
Add Another Trade Reference?

YesNo
Trade Reference 2
Company Name
Contact Name

First NameLast Name
Title / Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Fax Number
Email
Add Another Trade Reference?

YesNo
Trade Reference 3
Company Name
Contact Name

First NameLast Name
Title / Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Fax Number
Email
Print Name*
Signature*

Clear
Date*

MonthDayYear
This credit application is submitted by the Applicant to Access Display Group Inc. for the purpose of acquiring net terms with Access Display Group Inc. The Applicant acknowledges and agrees that Access Display Group Inc.'s review of this credit application does not ensure that the Applicant will be given Net Terms. Access Display Group Inc. reserves the right to accept or reject any application submitted, at its sole discretion. THIS APPLICATION IS ONLY EFFECTIVE AND BINDING UPON ACCESS DISPLAY GROUP INC. APPROVED CONFIRMATION OF THE APPLICANT. FAILURE TO COMPLETE ALL SECTIONS OF THIS CREDIT APPLICATION AS REQUIRED WILL RENDER THIS APPLICATION INADMISSABLE. Applicant acknowledges and agrees that participation in the Net Terms program is at-will and subject to Access Display Group Inc.'s right to revoke or terminate status, with or without cause, at any time. Applicant expressly acknowledges and agrees that the termination provisions provided herein are reasonable, and agrees not to contest or otherwise challenge such provisions, or to claim damages as a result of termination by Access Display Group Inc.
BY SIGNING ABOVE, THE APPLICANT REPRESENTS AND WARRANTS TO ACCESS DISPLAY GROUP INC. THAT THE INFORMATION PROVIDED TO ACCESS DISPLAY GROUP INC. IS TRUE AND ACCURATE, AND AGREES THAT DURING THE TERM OF ITS STATUS, IT SHALL PROMPTLY PROVIDE ACCESS DISPLAY GROUP INC WITH DETAILS REGARDING ANY MODIFICATIONS OR CHANGES TO SUCH INFORMATION. IN THE EVENT THAT SUCH INFORMATION IS DETERMINED TO BE INACCURATE, ACCESS DISPLAY GROUP INC. MAY IMMEDIATELY TERMINATE APPLICANT'S STATUS. APPLICANT SHALL BE LIABLE TO FULLY INDEMNIFY ACCESS DISPLAY GROUP INC.FOR ANY DAMAGES OR COSTS INCURRED BY ACCESS DISPLAY GROUP INC. AND RESULTING FROM OR AS A RESULT OF THE PROVISION OF SUCH INACCURATE INFORMATION BY APPLICANT.
Should be Empty:

Credit Application

Billing Information

Trade Reference 1

Trade Reference 2

Trade Reference 3