Credit Application Credit Application Business Information: Business Structure Sole Proprietorship Partnership Corporation Business Name Phone Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal A/P Contact * A/P email address * AP Phone Resale# Years in business 12345678910111213141516171819202122232425>25 Annual Sales ($) Federal ID# Number of employees Federal ID# Number of Employees Bank information: Bank Name Branch Address/Location Bank Contact Phone Checking Account Number Routing Number Trade References Business Name Phone Account # Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal plus1 Add minus1 Remove Officers / Partners: Name Name First First Last Last Phone Title Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal plus1 Add more minus1 Remove If credit is granted I (we) promise to pay bills when rendered. I (we) understand all invoices are payable in 30 days from invoice date and that a service charge of 1 1/2% per month will be added to my (our) past due account. In the event payment is not made and my (our) account is referred to a collection agency, I (we) will pay all costs of collection. If legal action is required I (we) will pay reasonable attorney’s fees resulting from such action. I (We) authorize the above-listed Bank(s) and trade references to release to Etched Media Corporation credit or financial information as required. I (We) further agree to comply with Etched Media Corporation’s attached terms and conditions. Name Name First First Last Last Title Date Signature Clear This form will be submitted to account@etchedmedia.com Click here to view our Terms and conditions Submit If you are human, leave this field blank.
