Credit Application

For an alternate Faxable/Print version click here.

Company Name:
Phone#:
County:
Date Established:
Billing Address:
Fed ID No:
City:
State:
Zip:
Ship To Address:
City:
State:
Zip:
Nature Of Business:
Tax Status:
If Exempt, copy of certificate must be faxed to 850-434-1900
P.O. Required:
A/P Contact:
D-U-N-S#:

Credit References

  1. Company Name Address
    City, State Zip Phone#
  2. Company Name Address
    City, State Zip Phone#
  3. Company Name Address
    City, State Zip Phone#

Bank References

  1. Bank Name Contact
    Type Of Account Phone#
  2. Bank Name Contact
    Type Of Account Phone#

A service charge of 1.5% per month will be assessed on all past due balances. Terms: Net 30 days unless otherwise stated on invoice. This charge is subject to change at any time.

The above information is provided for the purpose of obtaining credit and is warranted to be true. I hereby authorize Memphis Technology to investigate the references listed relating to my/our credit and financial responsibility.

Date: Authorized Name: Title:

Pressing Submit acts as your signature to this Credit Application.

 

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