Credit Application Form voice

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Credit Application Form voice

Credit Application Form
voice: 800-621-1296 or 773-248-0099
fax: 800-99FAXUV or 773-880-6647

To avoid any delay in processing, complete in full. All information to be held in confidence.

Billing Information
Company Name:
Accounts Payable Contact Person:
Billing Address:

City:
State/Province:
Postal Code:
Country:
Billing Phone:

General Business Information
Type of Business:
Years in Business:
Year of Incorporation:
State of Incorporation:
Dun and Bradstreet #:
D&B Rating:
Officer's Name:
Title:
		Are you sales/and or use tax exempt?yes no
		If yes, list certificate number:
Authorized UV Lamp Purchaser:
Type of Lamp Purchased:

Business Credit References

Name	Address	City	State	Zip Code	Phone #	Fax #

Bank Reference
Bank Name:
Officer Handling:
Address:

City:
State/Province:
Postal Code:
Country:
Phone:
Checking Account #:
Savings Account #:
Other:

We certify that all information on this form is correct; and that we fully understand your credit terms (net 30 days of date of invoice) and agree to the

proper payment in consideration of extended credit. This application will not be processed unless all questions are answered completely.

THIS FORM COMPLETED BY: _____________________________________

TITLE: _____________________________ DATE: ___________________

1229 W. Cortland St. · Chicago, IL 60614-4805 · Phone: 1-800-621-1296 OR 773-248-0099 · Fax: 1-800-99FAXUV OR +1-773-880-6647· Email: info@uvps.com
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