Tel: 951-270-1911 ** Fax: 951-304-1267 ** Email: sales@e-scan.com
CREDIT APPLICATION




Requested terms (check one)
_____________COD-company check
_____________Amount
_____________Net 30 days open account
_____________ Amount
Company or Corporate Name
(Exact Legal Name)

 

Doing Business As

 

Telephone No.

 




Billing Address



City  




State




Zip Code




Shipping Address
(if more than one,
attach separate list)

 

 

City  

 

 

State

 

 

Zip Code

Business is a: (check one) __ Corporation __ Partnership __ Proprietorship

(check one) __ Principal __ Partner __ Proprietor

Year Started___________ State of Inc._____________________

Name:___________________________________________________

Are you a __ subsidiary or __ division

Home Address:____________________________________________

Parent Company Name:___________________________________________

City:_____________________State:______________Zip:__________

Address:_______________________________________________________

Home Phone:______________________________________________

City:___________________________State:_____________Zip:__________

 

Fax No._________________________________________________

Accts. Payable Contact_____________________________________________

Name of Controller________________________________________

Phone__________________________________________________________

Has this firm ever filed for bankruptcy?_________(Y/N) If yes, please attach explanation.

DUN's #_________________________________

Do you require a purchase order number before we accept an order?_____________(Y/N)


Bank References
Bank/Bank Officer

 

Phone No.

 

Bank/Credit Dept. Fax No.

 

Street Address

 

City, State, Zip Code

 

Date Opened

 

Type of Account: __ Checking No.__________________ __ Savings No._________________ __ Loan No.___________________

Credit References (Major Suppliers)
1. Name

 

Contact Name

 

Phone No.

Fax No.

Street Address

 

City, State, Zip Code

 

Account No.

 

2. Name

 

Contact Name

 

Phone No.

Fax No.  

Street Address

 

City, State, Zip Code

 

Account No.

 

3. Name

 

Contact Name

 

Phone No.

Fax No.  

Street Address

 

City, State, Zip Code

 

Account No.

 

4. Name

 

Contact Name

 

Phone No.

Fax No.  

Street Address

 

City, State, Zip Code

 

Account No.

 

This credit application and agreement is submitted by Customer to Escan in order to obtain trade credit. Customer agrees to make payment in full to Escan for all amounts due according to Escan's invoice on or
before net due date. Customer also agrees to pay interest on all amounts that are past due. Interest can be charged monthly at 1.5%. If Customer should default in any payment(s), declare all Escan has reserved the
right to invoice amounts due and payable without notice to Customer. Additionally, Customer will be responsible for all collection costs and attorney fees, whether suit is filed or not, in order to collect any delinquent
amount. Customer also agrees to provide undersigned certifies that all of the information Escan with updated credit information on request and to provide an annual statement to Escan as a condition for the continued
extension of credit. The contained herein is true and correct to the best of their information, knowledge and belief. Customer agrees to adhere to credit/service policies established by Escan.

 

____________________________________________________________________________________________________________________________________________________________
Authorized Individual (Print Name)                                              Signature                                      Title                             Date
 

Consent Form Authorization

This form may be reproduced or photocopied and that copy shall be as effective consent, as the original which I/we signed.

SIGNATURE:___________________________________________

SIGNATURE:___________________________________________

DATE:________________________________________________

COMPANY NAME:_______________________________________________________________

I hereby give my/our consent to have Escan obtain any and all information concerning my/our checking and/or savings accounts, obligations and all other credit matters which may be required in connection with my/our application for a dealership and/or credit from Escan.



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Tel: 951-270-1911 ** Fax: 951-304-1267 ** Email: sales@e-scan.com