Credit Application - Display Specialties Inc.

Display Specialties Inc. Credit Application

*Bold fields are required.

Company Information Company Name:
Address Line 1:
Address Line 2:
City:
State (XX):
Zipcode:
Main Phone:
Fax Number:
Principal Contact:
Contact's Title:
Principal's Email: Your email address is safe with us.
DUNS Number:
Rating:
Years in Business:
Years in Business:
Number of Employees:
Type of Company:
Website address:
Sales Tax Exemption # :
Federal I.D. # :
How did you hear about DSI (referred by):
Products you are interested in:
Present Supplier:
Estimated Annual Purchases:
Estimated date of first order:

Accounting / Billing Information Bill to Address:
Attn:
A/P Contact:
PO# Required:
A/P Phone:
A/P Fax:
A/P Email:
Purchasing Contact:
Purchasing Phone:
Purchasing Email:

Bank Information Bank Name:
Account Number:
Bank Address:
Account Type:

Trade References Company Name:
Company Address:
Account Number:
Account Type:
Accounting Contact:
Accounting Email:
Telephone:
Fax:

Company Name:
Company Address:
Account Number:
Account Type:
Accounting Contact:
Accounting Email:
Telephone:
Fax:

Authorization To Release Information

The information supplied in this Credit Application and all forms and documents submitted to Display Speciaties Inc. in connection herewith is true and correct to the best of my/our knowledge and belief. I/we hereby authorize Display Speciaties Inc. to investigate my/our financial responsibility and credit worthiness and will provide financial statement, tax returns, and or other materials or information as requested by Display Speciaties Inc. and to verify any information provided from any source Display Speciaties Inc. may choose. I grant Display Speciaties Inc. the right to procure any and all credit or other investigative reports to any party to this application. I grant Display Speciaties Inc. the right to release any of the information contained herein or any results from any investigation of the information contained herein to any third party that may become part of any financing transaction between applicants and Display Speciaties Inc. or to whom Display Speciaties Inc. may refer this applicant to for funding. I further grant to any source from which Display Speciaties Inc. has requested information about applicants, the authorization to release such information to Display Speciaties Inc. An electronic mail (email ) copy, photocopy, or fax copy of this authorization may be accepted as an original.

Consent of Authorization

Type in first and last name as consent of authorization to release information:

Signature:
Title:
Date: