Credit Application Form

Tel: 626-810-8341
Fax: 626-810-8313
www.lanstreet.com

 
Company Reference    
   
Company Name ________________________________________________________________
DBA ________________________________________________________________
Billing address ________________________________________________________________
Shipping address ________________________________________________________________
Telephone No. ___________________ Fax No. ________________
Website ________________________________________________________________
Dun&Bradstreet No. ___________________ Annual Sales ________________
Federal ID No. ___________________ Date of Incorporated ________________
Ownership [ ] Individual [ ] Partnership [ ] Corporation
  [ ] LLC [ ] Other: ________________
Type of Business [ ] Distributor [ ] Reseller, Reseller ID.: ________________
  [ ] System Integrator [ ] Other: ________________
       
Officers Contact Information    
       
President ___________________    
       
Account Payable ___________________ Telephone No. / Ext. ________________
Fax No. ___________________ E-mail Address ________________
Buyer ___________________ Telephone No. /Ext. ________________
Fax No. ___________________ E-mail Address ________________
       
Bank Reference    
       
Name ___________________ Name ________________
Address ___________________ Address ________________
  ___________________   ________________
  ___________________   ________________
Telephone No. ___________________ Telephone No. ________________
Fax No. ___________________ Fax No. ________________
Contact ___________________ Contact ________________
Account No. ___________________ Account No. ________________
Account Type [ ] Checking Account Type [ ] Checking
  [ ] Saving   [ ] Saving
       
Trade Reference    
   
Company Name 1. ______________________________________________________________
Contact Person ________________________________________________________________
Telephone No. ________________________________________________________________
Fax No. ________________________________________________________________
E-mail Address ________________________________________________________________
       
Company Name 2. ______________________________________________________________
Contact Person ________________________________________________________________
Telephone No. ________________________________________________________________
Fax No. ________________________________________________________________
E-mail Address ________________________________________________________________
       
Company Name 3. ______________________________________________________________
Contact Person ________________________________________________________________
Telephone No. ________________________________________________________________
Fax No. ________________________________________________________________
E-mail Address ________________________________________________________________
       
Where did you first hear of Lanstreet?
[ ] Sales Call [ ] Referral [ ] Magazine/News Media [ ] Friend
[ ] Search Engine: __________________ [ ] Price Comparison Site: _________________
[ ] Other:   ___________________________________________________________
       
All Statements made herein are true and accurate to the best of our knowledge. We authorized Lanstreet.com to make any and all enquires necessary for action on this credit application. We hereby indemnify Lanstreet.com from any liability resulting from their credit survey.
Authorized Signature: _________________________________________________
   
Title:
Date:    /     /         
   
       
Sales Representative for this account: Account No.
[ ] Credit Approved Credit Approved By:
Amount:    
[ ] Credit Declined Credit Disapproved By:
Reason:  
Date:    /     /