Firm Name
|
Phone No. |
Fax No. |
Mailing Address
|
City
|
State
|
Zip
|
Shipping Address
|
City
|
State
|
Zip
|
(please check correct
box)
Sole Proprietorship |
F.E.I.N
|
Corporation
I.D.#
|
Incorporated:
|
Partnership |
State:
|
Corporation |
Year:
|
PRINCIPALS/OFFICERS |
Name
|
Address
|
City, State
|
Social Sec#
|
Name
|
Address
|
City, State
|
Social Sec #
|
Name
|
Address
|
City, State
|
Social Sec #
|
Name
|
Address
|
City, State
|
Social Sec #
|
Name
|
Address
|
City, State
|
Social Sec #
|
Name
|
Address
|
City, State
|
Social Sec #
|
BASIC BUSINESS INFORMATION |
Years In Business
|
Credit Line Desired
|
No. of Employees
|
Annual Sales
|
Type Of Business
|
Name of applicant's employee to be contacted by
AVT, Inc.
|
Have You Ever
Declared Bankruptcy?
Yes No |
If so, please give a brief explanation of the
circumstances of the bankruptcy. (you may attach additional sheets of
paper if necessary.)
|
BANKING INFORMATION |
| Contact |
Phone No. |
Fax No. |
Checking Acct. #
|
Savings Acct. #
|
| Credit Line |
Bank
|
Mailing Address
|
City, State, Zip
|
REFERENCES (List
only those accounts with open terms) |
| Name |
Contact |
City |
Phone |
Office Use |
| |
|
|
|
|
| |
|
|
|
|
| |
|
|
|
|
ACCOUNT AGREEMENT |
By affixing their signatures below, the undersigned (if
a corporation, the Corporate authorized officers/agents) agree:
1. That the information contained herewith is warranted to be true
and correct.
2. To pay when due. all invoices from American Video Tape
Warehouse.
3. That in the event of default of payment when due, all costs of
collection, including attorney's fees and court costs, shall be
paid by the applicant.
4. To authorize American Recordable Media to investigate any
references herein listed or statement of any other data obtained
from any person pertaining to the credit worthiness and financial
responsibility of the applicant. |
Name
|
Signature
|
Title
|
Date
|
Name
|
Signature
|
Title
|
Date
|
Need Help? Call
Toll Free: 1-800-598-8273
Fax: 859-296-4737 |
