TechXtend - Corporate Account Application Form

Corporate Account Application

Customer Information

Company Name *

Legal DBA Name *

Business Type *

Date of Business Established

Country *

Address 1 *

Address 2

City *

State / Province *

Zip / Postal Code *

Phone *

Fax

Tax Information

US Tax Number *

PST Number *

Are you PST exempt?

Accounts Payable Contact

Name *

Phone *

Fax

Email *

Dun & Bradstreet #

Bank Information

Bank Name *

Country

Address 1

Address 2

City

State / Province

Zip / Postal Code

Account Number *

Main Phone *

Main Fax *

Contact Name *

Contact Email *

Trade References

Reference 1

Company Name *

Country *

Address 1 *

Address 2

City *

State / Province *

Zip / Postal Code *

Phone *

Contact Name *

Contact Email *

Reference 2

Company Name *

Country *

Address 1 *

Address 2

City *

State / Province *

Zip / Postal Code *

Phone *

Contact Name *

Contact Email *

Reference 3

Company Name *

Country *

Address 1 *

Address 2

City *

State / Province *

Zip / Postal Code *

Phone *

Contact Name *

Contact Email *

Application Submission

* Permission is granted to TechXtend, to obtain credit information from all listed trade and bank references. I understand that the credit terms are net 30 days from date of invoice unless otherwise stated, and that the account may be subject to a finance charge on past-due balances of 1.5 % per month (18% per annum). I understand that orders may not be shipped if the account is past due. I certify that all information contained in this credit application is correct in all respects. I also certify that I am an authorized signing official of the Company named above.

Name *

Title *

Date