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Previous PageDealer Application
Date:_____________________
1. COMPANY PROFILE
Name of Firm:____________________________________________________________________________
Tel:______________________ Fax:_______________________Email:_______________________________
Street Address:___________________________________________________________________________
City:__________________________________________ State:_____________
Zip:____________________
Website Address:_______________________________
We are set-up as a:[ ]Proprietorship [ ]Partnership [ ]Corporation
Name & Home Address of Proprietor or of Partners (Please Print)
a. Name:__________________________________________________________ Title:__________________
Address:________________________________________________________________________________
City:________________________________________________ State:_____________ Zip:______________
b. Name:__________________________________________________________ Title:_________________
Address:_______________________________________________________________________________
City:________________________________________________ State:_____________ Zip:_____________
If Corporation, Officers' Names:
President:_______________________________________________________
Buyer:__________________________________________________________
Payables:________________________________________________________
Date Business Established:______________ How long at present location:_________________________
Federal Tax ID #:_______________________________ Resale Number:__________________________
2. BANK REFERENCES
Name:_________________________________________ Tel:_________________Fax:__________________
Address:________________________________________________________________________________
City:_______________________________________________ State:____________ Zip:________________
Type and Number of Account: [ ]Checking [ ]Savings
3. TRADE REFERENCES
a. Name:________________________________________ Tel:________________Fax:__________________
Address:________________________________________________________________________________
City:______________________________________________ State:______________ Zip:_______________
FAX:_________________________________________ Credit limit:____________________
b. Name:________________________________________ Tel:________________ Fax:_________________
Address:________________________________________________________________________________
City:_____________________________________________ State:_______________ Zip:_______________
FAX:_________________________________________ Credit limit:____________________
c. Name:________________________________________ Tel:___________________Fax:_______________
Address:________________________________________________________________________________
City:_____________________________________________ State:______________ Zip:________________
FAX:_________________________________________
Credit limit:____________________
AUTHORIZED SIGNATURE:___________________________________ TITLE:_______________________ DATE:________
Customer shall be responsible for all legal and collection fees in regard to this account. No returns allowed without RMA number. No refunds allowed after 30 days from the date of invoice. There will be a $25 charge for any returned checks. 1.5% finance charge will be applied to any invoice which is past due. There will be a $30 diagnosis charge for items returned as defective and test good.
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.
Escan Technologies Corp.
12140 Severn Way
Riverside, CA 92503
Toll Free# 1-800-653-4252 Int'l# 951-270-1911 Fax# 951-270-0920
