Online Form - Please make sure you have completely filled out this application before submitting.
 
  CREDIT APPLICATION
Company Name:   Date:
Address:
City:
State:  Zip:
   
Billing:
City:
State:  Zip:
   
Phone:   Fax:
   
Type of Business:   Date Established:
This is a: Corporation  Sole Proprietorship  Partnership   Other: 
If incorporated, under the laws of what state:  Federal Tax ID#:
   
Owner/Officer's Name:
Address:
City:
State:  Zip:
Title:   SS#
 
  TRADE REFERENCES
Name:   Credit Limit:
Address:
City:
State:  Zip:
Phone:   Fax:
Doing Business Since:   Contact:
   
Name:   Credit Limit:
Address:
City:
State:   Zip:
Phone:   Fax:
Doing Business Since:   Contact:
   
Name:   Credit Limit:
Address:
City:
State:   Zip:
Phone:   Fax:
Doing Business Since:   Contact:
 
  BANKING REFERENCE
Bank:   Account #:
Address:
City:
State:  Zip:
Phone:   Fax:
Banking Since:   Contact:
 
  TERMS
  In consideration of CyberCopy (Seller), selling goods and/or services to the buyer, executing this application and agreement, buyer agrees to the following terms and conditions:
Payment is due and payable 30 days from the date of invoice. All past due invoices will carry an additional finance charge of 1.5% per month, 18% annually and such interest charge will be due and payable immediately. Any dispute as to billing, charges or materials must be raised by buyer within 15 days of the invoice date or said dispute shall be waived by buyer.

THE UNDERSIGNED WARRANTS THAT HE/SHE IS AUTHORIZED TO EXECUTE THIS CREDIT APPLICATION ON THE PART OF THE BUYER AND TO BIND BUYER TO ITS PROVISIONS. SIGNATURE ALSO REPRESENTS BANK AND CREDIT RATING AUTHORIZATION.
   
Signature:
(must be owner, party, or officer)		 ____________________________________
Print:
Title:
Date:
Amount of Credit Requested:
 
  Please make sure you have completely and correctly filled out this application before submitting. After submitting, this application will be sent to CyberCopy for review. A copy will be mailed to you for your signature. You will have an opportunity to print this application for your own records on the next page.
   
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