Credit Application

BUSINESS CONTACT INFORMATION

Title

Company Name

Fax

Phone

Address

State

City

Zip Code

Date Business Commenced

Formation type

Sole Proprietorship:

Partnership

Corporation

Other

Other:

EIN Number

BUSINESS AND CREDIT INFORMATION

Primary Business Address

State

City

Zip Code

Phone

Fax

Bank Name

Bank Address

State

City

Zip Code

Type of Account

Account Number

Checking

D&B Number

BUSINESS/TRADE REFERENCES

Company Name (1)

Address

State

City

Zip Code

Phone

Fax

Type of Account

Company Name (2)

Address

State

City

Zip Code

Phone

Fax

Type of Account

Company Name (3)

Address

State

City

Zip Code

Phone

Fax

Type of Account

AGREEMENT

All invoices are to be paid 30 days from the date of the invoice.
By submitting this application, you authorize ICP DAS USA, INC. to make inquiries into the banking and business/trade references that you have supplied.

SIGNATURES

Title

Name

Date

Title

Name

Date

If you are human, leave this field blank.

Credit Application

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