Credit Application
Please complete the application below by filling in the fields.
Applicant Credit Application
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
President/CEO
First Name
Last Name
A/P Contact Phone Number
Please enter a valid phone number.
A/P Contact Email
example@example.com
Applicant Firm is:
Corporation
Partnership
LLC
Proprietorship
Federal Tax ID # or Social Security #. Please send Form 5000.
Tax Exempt status
Yes, please provide tax exempt certificate
No
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Bank Reference
Bank
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Contact Name
First Name
Last Name
Account Number
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Credit References
Credit Reference 1
Please provide all three references.
#1 Company Name
Account Number
Contact Name
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Contact Email
*
example@example.com
Credit Reference 2
Please provide all three references.
#2 Company Name
Account Number
Contact Name
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Contact Email
*
example@example.com
Credit Reference 3
Please provide all three references.
#3 Company Name
Account Number
Contact Name
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Contact Email
*
example@example.com
Credit Amount Requested:
Please complete with credit value requested.
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Credit Terms & Conditions
Applicant warrants that the above information is true and accurate. I/We authorize Ordertech Acquisition One, INC DBA Circuit Specialists to contact the references to investigate Applicants credit and financial responsibility. I certify that on behalf of Applicant I am familiar with the terms of Net 30. Failure to abide by the terms and conditions shown may result in interest and/or late fees being assessed to Applicant's account.
Signature
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: