Please print out this form, fill out completely and fax to IMTEK at:
(770) 667-8683.
Name_________________________________________________________
Title_________________________________________________________
Company_________________________________________________________
Address_________________________________________________________
City_________________________________________________________
State_________________________________________________________
Zip_________________________________________________________
Country_________________________________________________________
Phone_________________________________________________________
FAX_________________________________________________________
E-mail_________________________________________________________
PRINCIPALS (if corporation, list
officers, if partnership, list partners)
1. Name_________________________________________________________
Title_________________________________________________________
Home Address_________________________________________________________
City_________________________________________________________
State_________________________________________________________
Zip_________________________________________________________
Country_________________________________________________________
Phone_________________________________________________________
---------
2. Name_________________________________________________________
Title_________________________________________________________
Home Address_________________________________________________________
City_________________________________________________________
State_________________________________________________________
Zip_________________________________________________________
Country_________________________________________________________
Phone_________________________________________________________
----------
3. Name_________________________________________________________
Title_________________________________________________________
Home Address_________________________________________________________
City_________________________________________________________
State_________________________________________________________
Zip_________________________________________________________
Country_________________________________________________________
Phone_________________________________________________________
SALES TAX STATUS
(Please check one)
Not Tax Exempt____
Tax Exempt ____ Tax Exempt Number__________________
BANK REFERENCE
Bank Officer_________________________________________________________
Bank Name_________________________________________________________
Address_________________________________________________________
City_________________________________________________________
State_________________________________________________________
Zip_________________________________________________________
Country_________________________________________________________
Phone_________________________________________________________
Account #_________________________________________________________
TRADE REFERENCES
1. Contact Name_________________________________________________________
Company_________________________________________________________
Address_________________________________________________________
City_________________________________________________________
State_________________________________________________________
Zip_________________________________________________________
Country_________________________________________________________
Phone_________________________________________________________
----------
2. Contact Name_________________________________________________________
Company_________________________________________________________
Address_________________________________________________________
City_________________________________________________________
State_________________________________________________________
Zip_________________________________________________________
Country_________________________________________________________
Phone_________________________________________________________
----------
3. 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% 10; 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________________
