CREDIT APPLICATION Please fill in all of the information and press the Submit button. Bill to Address for Invoices: First Name: Last Name: Company: Address: Address (contd): City: State: Zip: Phone Number: Fax: Requested Credit Limit: $      D & B # NCI use only: Order # pending: Amount: $ Sales Tax Status if exempt, please enter NYS tax exempt certificate #'s here: **Special Billing Requirements:        **A/P Contact Name & Phone Number:        A/P Email Address:        REFERENCES (Minimum of 1 bank and 3 trade required) BANK REFERENCE Bank Name: Street Address: Street Address 2: City: State: Zip: Phone: Fax: Account #(s): TRADE REFERENCES Trade Reference Number 1. Company: Address: Address (contd): City: State: Zip: Phone Number: Fax: Trade Reference Number 2. Company: Address: Address (contd): City: State: Zip: Phone Number: Fax: Trade Reference Number 3. Company: Address: Address (contd): City: State: Zip: Phone Number: Fax: Trade Reference Number 4. Company: Address: Address (contd): City: State: Zip: Phone Number: Fax: I am applying for credit with Northeast Controls, Inc, and agree to pay within their terms of Net 30 from Invoice Date and subject to the Company's standard Terms and Conditions of Sale. I understand these terms and agree to the proper payment in consideration of extended credit. I also give permission to contact the bank and trade references above for account information. "Electronic Signature"     Date: