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General Business Credit Application, Form W-9 - Request For Taxpayer Identification Number And Certification

GENERAL BUSINESS CREDIT APPLICATION

Account #:

Sales Rep:

INSTRUCTIONS: Complete all sections (missing information will delay processing).Sign appropriate sections on the form and fax to CREDIT 800.327.2679

Legal Name of Business:

DBA: (Same as or enter name)

Billing Address:

STREET

P.O. BOX

CITY/STATE

ZIP

Place of Business □ Commercial

□ Residential

DUNS# ___________________________________

Business Phone:

________ Fax #: _________________ A/P Name: ____________________ A/P E-Mail:

□ Corporation

□ Sole Proprietor

□ Partnership

□ LLC

□ Other____________________

Your estimated annual sales/revenue? $

Estimated annual purchases from Copylite Products? $

Number of Employees: Office:

# of Technicians:

□ Taxable

□ Non-Taxable

If sales tax-exempt, certificate must be provided.

PRINCIPALS:

Full Name

Home Address & Phone #

Title

1).

2).

3).

TRADE REFERENCES:

Name

Account #

Address & Phone #

Fax #

1).

2).

3).

CONDITONS AND AGREEMENT OF CREDIT SALES - CREDIT AUTHORIZATION

(MUST BE SIGNED BY AN AUTHORIZED CORPORATE OFFICER / PLEASE SEE TERMS AND CONTIDIONS ON PAGE 2)

Signature

Title

Printed Name

Date:

PERSONAL GUARANTEE

)

(MUST BE SIGNED BY AN AUTHORIZED CORPORATE OFFICER / PLEASE SEE TERMS AND CONDITIONS ON PAGE 2

Guarantor’s Signature:

Date

SS#

Guarantor’s Home Address:

City, State & Zip:

Witness’s signature:

Witness’s Printed Name:

Bank Authorization Release Form

(MUST BE COMPLETED AND FAXED TO BANK)

Company Name:

Account#

Bank Name:

Bank Contact:

Address:

Telephone No:

Fax No.:

, Owner/Principal/Officer of

Give authorization for any banking information to be released to Copylite Products:

By:

Title:

Date:

New Town Commerce Centre ● 4061 SW 47

Avenue ● Fort Lauderdale, FL 33314

Phone 800.989.6000 Ext 272

Fax 954.791.6322

General Business Credit Application, Form W-9 - Request For Taxpayer Identification Number And Certification

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