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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
| 1.
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
Escan Technologies Corp. 12140 Severn Way, Riverside CA 92503 * (800) 653-4252 * FAX (951) 270-0920
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.
