Electrol Systems, Inc.

 

(210) 599-6485

FAX (210) 599-6487

(888) 853-8944

10623 Sentinel Drive - San Antonio, TX 78217

FAX (888) 853-8945

CREDIT APPLICATION FORM

 COMPANY NAME:

DATE:

TELEPHONE:

FAX:

ADDRESS:

CITY:

STATE: ZIP:

 FORM OF ORANIZATION

[ ] CORPORTION

[ ] PROPRIETORSHIP

[ ] PARTNERSHIP

[ ] OTHER:

 DATE BUSINESS ESTABLISHED:

TYPE OF BUSINESS:

NAMES OF INDIVIDUALS RESPONSIBLE FOR PAYMENT OR TO CONTACT FOR PAYMENT:

1.

TITLE:

2.

TITLE:

OFFICERS NAME

TITLE

PHONE

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2.

 

 

BANK REFERENCE

BANK NAME:

CONTACT:

BANK ADDRESS:

PHONE:

CITY:

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[ ] CHECKING ACCOUNT

ACCOUNT NO:

[ ] OTHER:

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TRADE REFERENCES

NAME

ADDRESS

PHONE

FAX

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ARE YOU TAXABLE? [ ] YES [ ] NO

IF NO, ATTACH "BLANKET CERTIFICATE FOR RE-SALE"

CONFIDENTIAL FINANCIAL STATEMENT WILL BE GREATLY APPRECIATED.

WE HAVE READ ELECTROL SYSTEMS "TERMS OF AGREEMENT" AND FULLY UNDERSTAND THEM AND WE ARE WILLING TO UPHOLD THEM WITH NO CHANGES.

SIGNATURE:

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