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Air Sanitizer, Air Purifier & Deodorizer Lights

Air Sanitizer, Air Purifier & Deodorizer Accessories

SaniGuard™ Sanitizing Fluorescent Light Guards

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Pesteze™ Bug Repellent CFL Bulbs

SaniBulb™ Sanitizing CFL Bulbs

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PurAyre™ Ionic Air Purifiers

Smelleze™ Eco Deodorizers

SteriBrush™ Toothbrush Sanitizers

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Online Distributor/Credit Application Form

Note: This is an HTML form. You MUST have a browser that supports forms in order to use it.
Please fill the form in carefully. If you have difficulties, send e-mail directly to: IMTEK

Please fill out form completely and carefully.

ADDRESS

Name:
Title:
Company:
Address:
City:
State:
Zip:
Country:
Phone:
FAX:
Email:

_____________________________________________________________________

PRINCIPALS (if corporation, list officers, if partnership, list partners)

Name:
Title:
Home Address:
City:
State:
Zip:
Country:
Phone:

_____________________________________________________________________

Name:
Title:
Home Address:
City:
State:
Zip:
Country:
Phone:

_____________________________________________________________________

Name:
Title:
Home Address:
City:
State:
Zip:
Country:
Phone:

_____________________________________________________________________

SALES TAX STATUS Not Tax Exempt Tax Exempt --- Exempt #

_____________________________________________________________________

BANK REFERENCE

Bank Officer:
Bank Name:
Address:
City:
State:
Zip:
Country:
Phone:
Account #:

_____________________________________________________________________

TRADE REFERENCES

Contact Name:
Company:
Address:
City:
State:
Zip:
Country:
Phone:

_____________________________________________________________________

Contact Name
Company
Address
City
State
Zip
Country
Phone

_____________________________________________________________________

Contact Name
Company
Address
City
State
Zip
Country
Phone

_____________________________________________________________________

BUSINESS INFORMATION

Individual
Partnership
Corporation

Type of Business
Number of Employees
Years in Business
Annual Sales $
D+B Listed? Yes No
Amount of Credit Requested $

_____________________________________________________________________

BY COMPLETING THIS APPLICATION FOR CREDIT, THE APPLICANT:

1.Attests financial responsibility, ability and willingness to pay all invoices
in accordance with the following terms: 2% 30; Net, 30 days, service charges will be
paid at the rate of 1.5% (18% annual rate) on all balances over 30 days.

2.Hereby Authorizes IMTEK. to investigate
the references listed pertaining to the applicant's credit and financial responsibility and
obtain additional information by securing data from a credit reporting agency.

3.Hereby Agrees that should it become necessary to assign the applicant's
account to a licensed collection agency or atttorney for legal action, all subsequent
collection charges and legal fees shall be paid by the applicant.

4. Hereby Authorizes the seller, its successors and assigns, by the seller's
designated attorney to waive the issuance of process and confess judgment against the
applicant for the entire unpaid balance of applicant's account together with all costs
applicable to such action.

5. Certifies and Warrants that the information given in this application is true and
correct and is given for the purpose of obtaining credit.

Applicant Name:
Position:
Date:

Applicant Name:
Position:
Date: