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CREDIT APPLICATION FORM


Company Info:    
Company Name:  
Phone #:  
Fax #:  
Billing Info:    
Address 1:  
City:  
State:  
Zip:  
Address 2:  
City:  
State:  
Zip:  
A/P Contact:    
Name:  
Email:  
Other Info:    
Type of Business:  
If a Corporation:    
  What Type?    C   S
  State of Incorporation:  
Business Start Date:  
FEIN:  
D&B No:  
Banking Reference:    
Name:  
Address:  
City:  
State:  
Zip:  
Phone #:  
Fax #:  
Account Officer:  
Trade References:    
Company 1:  
Contact:  
Address:  
City:  
State:  
Zip:  
Company 2:  
Contact:  
Address:  
City:  
State:  
Zip:  

PLEASE NOTE: Submitting this form indicates that you accept the terms and conditions stated below:

I understand that the information submitted herewith is confidential and for the purpose of establishing a credit account with Function5 Technology Group. I do hereby certify this information to be true and correct and I am authorized in my capacity to bind my company accordingly. Further, if credit is extended, and the entity is a Proprietorship, Partnership or S Corporation, the undersigned personally agrees to pay all monies when due and payable in Monroe County New York.

Should it be necessary to assign the account balance to a collection agency or attorney for legal action, the Applicant agrees to pay all collection charges and legal fees incurred by Function5 Technology Group to collect this debt.

I hereby authorize our bank(s) and/or references to release any information necessary to assist Function5 Technology Group in establishing a line of credit.