VP/Finance:_______________________________A/PManager:________________________________
financial statements, tax returns etc., as you deem necessary.
Ship to: (if different)
Net Worth ___________________
( ) Partnership
)
Check One: ( ) Corporation
Date
Contact Name: _____________________________
BANK INFORMATION
Phone No.: ________________________________ Fax No.: ______________________________
Phone: ____________________________________
Complete Address: ________________________________________________________________
( ) Subsidiary of or
Bohemia, NY 11716
Reference 1: ______________________________ Contact: _____________________________
00-000-0076
eele: Sales
of
Reference 2: _______________________________ Contact: _____________________________
President/CEO:_____________________________Treasurer/Controller:________________________
_______________
TRADE REFERENCES
( ) Proprietorship
Years in Operation: ___________
Legal Company Name: _____________________________________________________________
eele Laboratories, LLC
BUSINESS INFORMATION
Phone No.: ________________________________ Fax No.: ______________________________
Sales Per Year ___________________________________
Phone No.: ________________________________ Fax No.: _____________________________
50 Orville Dr.
Title
Bank: _______________________________
_______________________________________________________________________________
1 of 1
Prepared by (signature)
(
Type of Business: _________________________________
CREDIT APPLICATION- NET 30
CUSTOMER'S AUTHORIZATION TO RELEASE BANK AND TRADE INFORMATION
Reference 3: _______________________________ Contact: ______________________________
Attention Bank and Trade References: Please provide information on all accounts listed as well as any loan information. You will be serving our interest best if
D&B #: _______________________
________________________________________________________________________________
I/We hereby authorize you to whom this application is made, or your agents, to investigate my/our credit worthiness and will provide
BILLING/SHIPPING INFORMATION
E-mail: _____________________________
Main Phone:__________________ Main Fax:__________________ A/P Fax:___________________
________________________________________________________________________________
Please provide us with copies of all tax exemption certificates
Please Fax to: _____________________
Division
Website: ______________________________
Account No. __________________________
12/30/2005: 11:30 AM
you provide the information over the phone. Thank you.
Fax: (631) 244-0053
Bill to:
[Pag.1]
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