Credit Application Form

Company Information
Company Name:
Phone:
Fax:
Billing Info
Address 1:
City:
State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Address 2:
City:
State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
A/P Contact
Name:
Email:
Other Info
Type of Business:	Please Choose Corporation Partnership Sole Proprietor
If a Corporation:	What Type?    C   S
	State of Incorporation:  Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Business Start Date:
FEIN:
D&B No:
Banking Reference
Name:
Address:
City:
State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:
Account Officer:
Trade References
Company 1:
Contact:
Address:
City:
State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:
Company 2:
Contact:
Address:
City:
State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:

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.