CREDIT APPLICATION

Requested terms (check one)
__ COD-company check
___________________Amount
__ Net 30 days open account
___________________Amount

 

Company or Corporate Name (Exact Legal Name)

 

Doing Business As

 

Telephone No.

 

Billing Address

 

City

 

State

 

Zip Code

 

Shipping Address (if more than one, attach separate list)

 

City

 

State

 

Zip Code

 

 

Business is a: (check one) __ Corporation __ Partnership __ Proprietorship

(check one) __ Principal __ Partner __ Proprietor

Year Started___________ State of Inc._____________________ Name:___________________________________________________
Are you a __ subsidiary or __ division Home Address:____________________________________________
Parent Company Name:___________________________________________ City:_____________________State:______________Zip:__________
Address:_______________________________________________________ Home Phone:______________________________________________
City:___________________________State:_____________Zip:__________  

 

Fax No._________________________________________________ Accts. Payable Contact_____________________________________________
Name of Controller________________________________________ Phone__________________________________________________________
Has this firm ever filed for bankruptcy?_________(Y/N) If yes, please attach explanation. DUN's #_________________________________________
Do you require a purchase order number before we accept an order?_____________(Y/N)

Bank References

1. Bank/Bank Officer

 

Phone No.

 

Bank/Credit Dept. Fax No.

 

Street Address

 

City, State, Zip Code

 

Date Opened

 

Type of Account: __ Checking No.__________________ __ Savings No._________________ __ Loan No.___________________

Credit References (Major Suppliers)

1. Name

 

Contact Name

 

Phone No.

 

Street Address

 

City, State, Zip Code

 

Account No.

 

2. Name

 

Contact Name

 

Phone No.

 

Street Address

 

City, State, Zip Code

 

Account No.

 

3. Name

 

Contact Name

 

Phone No.

 

Street Address

 

City, State, Zip Code

 

Account No.

 

4. Name

 

Contact Name

 

Phone No.

 

Street Address

 

City, State, Zip Code

 

Account No.

 

This credit application and agreement is submitted by Customer to Incode Corp. in order to obtain trade credit. Customer agrees to make payment in full to Incode Corp. for all amounts due according to Incode Corp.'s invoice on or before net due date. Customer also agrees to pay interest on all amounts that are past due. Interest can be charged monthly at 1.5%. If Customer should default in any payment(s), declare all Incode Corp. has reserved the right to invoice amounts due and payable without notice to Customer. Additionally, Customer will be responsible for all collection costs and attorney fees, whether suit is filed or not, in order to collect any delinquent amount. Customer also agrees to provide undersigned certifies that all of the information Incode Corp. with updated credit information on request and to provide an annual statement to Incode Corp. as a condition for the continued extension of credit. The contained herein is true and correct to the best of their information, knowledge and belief. Customer agrees to adhere to credit/service policies established by Incode Corp..

 

___________________________________________________________________________________________________________________________
Authorized Individual (Print Name)                                              Signature                                      Title                             Date

Incode Corp. 12140 Severn Way, Riverside CA 92503 * (888) 272-9951 * FAX (951) 270-0937

 

Consent Form Authorization

This form may be reproduced or photocopied and that copy shall be as effective consent, as the original which I/we signed.

SIGNATURE:___________________________________________

SIGNATURE:___________________________________________

DATE:________________________________________________

COMPANY NAME:_______________________________________________________________

I hereby give my/our consent to have Incode Corp. obtain any and all information concerning my/our checking and/or savings accounts, obligations and all other credit matters which may be required in connection with my/our application for a dealership and/or credit from Incode Corp..

 

 

 

Return to Previous Page

Return to Home Page