Credit Application - Epsilon Electronics

Owner Information

Contact*

First NameLast Name

Title*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Bank References (Required)

Bank Name*

Contact Name*

Account #*

Phone Number*

Please enter a valid phone number.

Bank References #2 (Optional)

Bank Name

Contact Name

Account #

Phone Number

Please enter a valid phone number.

Trade References #1 (Required)

Company Name*

Contact Name*

Account #*

Phone Number*

Please enter a valid phone number.

Trade References #2 (Required)

Company Name*

Contact Name*

Account #*

Phone Number*

Please enter a valid phone number.

Trade References #3 (Optional)

Company Name

Contact Name

Account #

Phone Number

Please enter a valid phone number.

Signature*

Contact*

First NameLast Name

Today's Date*

Date

The undersigned hereby authorizes Epsilon Electronics, Inc. to make such inquiries necessary to obtain credit information and authorizes the bank(s) of record to release information regarding account(s). Upon failure of the buyer to pay any indebtedness to Epsilon Electronics, Inc. when due. In this event, upon notice to the buyer, the entire balance of all indebtedness shall become immediately due and payable. In the event of delinquency or default of the buyer, the undersigned agrees to pay Epsilon Electronics, Inc. standard late charges plus collection costs and attorney fees incurred by Epsilon Electronics, Inc. Signer agrees to be held personally responsible for any indebtedness incurred.

Credit Line/Terms Application

Owner Information

Bank References (Required)

Bank References #2 (Optional)

Trade References #1 (Required)

Trade References #2 (Required)

Trade References #3 (Optional)