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Confidential Credit Application




Privacy Statement


Please fill in the following form and click 'Submit' (at bottom of form).
Required fields are in bold.

Credit Amount Requested:

(Dataforth Standard Terms is Net 30, FOB Shipping Point)


Company Information
Company Name:

Billing Address:
 
City:
State:
Zip Code:
Phone:
Fax:
Federal ID#:
D&B #:

Shipping Address:
 
City:
State:
Zip Code:
Phone:
Fax:


Business Information
Individual Co-Partnership Limited Partnership Corporation
The company was founded in (year).
We have been at our present location for years.
Net Worth:
$
Estimated Annual Sales:
$
Estimated monthly purchases from Dataforth: $
Sales tax exemption number (if applicable):


Bank Reference
Bank Name:
Bank Officer's Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Account Number:


Trade Reference (1)
Company Name:
City:
State:
Zip:
Phone:
Fax:
Highest Amount
of Credit Granted:
$
Years of
Business Relationship:


Trade Reference (2)
Company Name:
City:
State:
Zip:
Phone:
Fax:
Highest Amount
of Credit Granted:
$
Years of
Business Relationship:


Trade Reference (3)
Company Name:
City:
State:
Zip:
Phone:
Fax:
Highest Amount
of Credit Granted:
$
Years of
Business Relationship:

Signature
By entering my name and clicking the 'Submit' button below, I agree that to the best of my knowledge, all statements made herein are true and accurate:
Name:
Title:
Phone:
Email:
Date:
5/17/2008
  Dataforth's Accounting Department will review your application and, after your trade references respond, you will be contacted and advised of our payment terms.