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 #:
Amount $:
Invoice Payment     ACH  EFT  CHECK


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:

TRADE REFERENCES

Trade Reference Number 1.

Company:
Address:
Address (contd):
City:
State:
Zip:
Phone:
Fax:

Trade Reference Number 2.

Company:
Address:
Address (contd):
City:
State:
Zip:
Phone:
Fax:

Trade Reference Number 3.

Company:
Address:
Address (contd):
City:
State:
Zip:
Phone:
Fax:

Trade Reference Number 4.

Company:
Address:
Address (contd):
City:
State:
Zip:
Phone:
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 the proper payment in consideration of extended credit. I also give permission to contact the bank and trade references above for acount information.

"Electronic Signature" Date:

 
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