| Contact Information |
Name: *
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Phone: *
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Fax:
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Email:
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Web site:
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Applicant's Legal Business Name & DBA's, if any: *
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Invoicing Address: *
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City: *
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State/Province: *
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Zip/Post Code: *
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Country:
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Physical Address (If different):
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City:
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State/Province:
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Zip/Post Code:
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Country:
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Business Style: *
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State/Province of Incorporation or Organization: *
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How Long in Business? (years) *
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If Subsidiary, Parent Corp:
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| Principal Owners/Officers (If partnership, all partners must be listed) |
Name: *
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Title: *
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Additional Principal Owners/Officers:
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| Bank Information |
Bank Name: *
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Account Number: *
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Address: *
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City: *
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State/Province: *
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Zip/Post Code: *
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Country:
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Phone: *
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Fax:
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Trade References (Provide three references from whom Applicant makes
purchases on a credit basis) |
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| Reference #1 |
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Name: *
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Address: *
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City: *
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State/Province: *
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Zip/Post Code: *
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Country: *
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Phone: *
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Fax:
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Email: *
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| Reference #2 |
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Name: *
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Address: *
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City: *
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State/Province: *
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Zip/Post Code: *
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Country: *
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Phone: *
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Fax:
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Email: *
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| Reference #3 |
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Name:
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Address:
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City:
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State/Province:
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Zip/Post Code:
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Country:
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Phone:
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Fax:
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Email:
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Important:
Be sure to read and check "I Agree" below to avoid delay in processing this request for credit. All information received is handled confidentially by Nunhems USA, Inc. credit services.
Authorization and Understandings:
Applicant hereby authorizes Nunhems USA, Inc. to request and extend credit information without liability on the part of Nunhems USA, Inc. and the Bank and Trade References provided above. I / We affirm all of the information provided is true, correct and complete. The undersigned warrants he/she is duly authorized by Applicant to sign this Application and Authorization and Understanding on Applicant's behalf. Applicant understands that past due amounts are subject to late Payment Penalty specified in applicable Price Lists, Orders, Invoices or other written notice. Applicant understands that in case of default or delinquency, Applicant is liable for reasonable attorney and collection agency fees and all other collection expenses.
Submission of this form does not guarantee that credit terms can be granted.
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Click here to acknowledge you have read and
agree to the Authorizations and Understandings
described above (REQUIRED): |
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A copy of submitted application will be emailed
to applicant's email address. |
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