Domestic customer profile, Account setup & Credit application

COMPANY INFORMATION :

* Name of Company :
* Street Address :
* Country :
City :
* State :
Postal Code :
* Telephone :
* E-Mail :
Name Owner :
* Credit Limit Desired $ :

PROCESSING ORDER INFORMATION :

Accounts Payable Contact Name :
E-mail :
Telephone :
Order Processing Contact Name :
E-mail Invoice :
Telephone :
Other Information :

BUSINESS TYPE:

Business Type :
Shipping Address if different than company address :
Address :
Address :
City :
State :
Postal Code :
Attention to :
GFI arranging Freight CPU (customer arranging Freight)

CREDIT REFERENCES :

Bank (Name) :
Bank Contact :
Full Address :
Dun & Bradstreet Number and Rating :

TRADE REFERENCES :

* Name :
* Address :
* City :
* State :
Postal Code :
Date of Last Purchase :
* Telephone :
* E-Mail :

As a holder of the above referenced credit account with your firm, I hereby authorize and request that the attached credit reference detailing our credit history with your firm be completed and forwarded to ACUSA, LLC.