CREDIT APPLICATION

Please make sure all information is complete.

Basic Information
business name
street address
city
state/province
postal code

county
years at this address
shipping address
city
state/province
postal code

county
federal id no.
dun & bradstreet no.
phone
fax
email
accounts payable contact
type of business
Company Principals
principal
title

principal
title

principal
title
Trade References of Major Products & Services
company name
address
city
state/province
postal code

phone
fax
company name
address
city
state/province
postal code

phone
fax
company name
address
city
state/province
postal code

phone
fax
Bank References
bank name
street address
city
state/province
postal code

phone
contact name
type of account

Has the Firm or any of its Principals ever been Bankrupt? Yes No

If Yes, Explain
AGREEMENT

I/We wish to establish credit with ProTech Systems, Inc. and certify that the above information is correct. Any false information may result in cancellation of credit privileges. I/We understand that the terms of ProTech Systems, Inc. are net 30 days from the date of invoice with interest on past due accounts charged at a rate of 1.5% per month (18.0% A.P.R.). I/We agree to comply with these terms if credit is extended. In the event that ProTech Systems, Inc. determines that collection and/or legal services will be necessary in order to collect amounts owed, all such costs of collection shall be added to the account and become the debtor’s obligation.

I/We understand that unless a valid sales tax certificate is presented, ProTech Systems, Inc. will assess appropriate sales tax to invoices. The undersigned grants his/her authorization to inquire from any of the provided references and receive from them any and all information regarding their accounts and payment history. All information provided will be held in strict confidence.

I Authorize This Credit Check

name
title