Min-Max Machine
Name ____________________________________________________________
Date ________________
Billing Address ____________________________________________________________________
City ________________________________________________________
State _____ Zip __________
Telephone ___________________________________
Fax _____________________________________
Years in Business _______ Corporation Partnership Proprietorship
NAME OF CORPORATE OFFICERS-OWNERS-PARTNERS
Name ___________________________________________________ Title
__________________________
Name ___________________________________________________ Title
__________________________
NAME AND ADDRESS OF PARENT COMPANY IF SUBSIDIARY
Name ___________________________________________________
Phone _________________________
Address _______________________________
City ____________________ ST ___ Zip _________
REFERENCES: List three firms where credit is established
1. Name ___________________________________________________
Phone ______________________
Address _______________________________
City ____________________ ST ___ Zip _________
2. Name ___________________________________________________
Phone______________________
Address _______________________________
City ____________________ ST ___ Zip _________
3. Name ___________________________________________________
Phone______________________
Address _______________________________
City ____________________ ST ___ Zip _________
BANK Account No. _____________________________ Type: Checking Loan Savings
Bank Name __________________________________________
Officer Name ______________________
Address _______________________________
City ____________________ ST ___ Zip _________
PURCHASE ORDER REQUIREMENTS: P.O. Required? Yes No
If P.O. not required, list individuals authorized to purchase or license creative services.
Name ___________________________________________________
Title __________________________
Name ___________________________________________________
Title __________________________
Signature authorizes the release of credit information from references listed. Applicant's signature attests to financial responsibility, ability and timeliness to pay invoices. Actual terms are specified on Estimate/Assignment Confirmation/Invoice forms accompanying all jobs and projects.
Name ___________________________________________________
Title __________________________
Corporate Officer or Owner
Please Print this form and fax to our office.
Fax: 631-585-4610