Credit Application

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Company Name:*

Previously known as:

Business Type:

D&B No:

FEI No:

Sales Tax Exemption No:

Sales Tax Exemption State:

Upload Tax Exemption Certificate:

Max. file size: 50 MB.

Billing Email:*

Billing Address:*

City:*

State:*

Zip Code:*

Country:*

Corporate Phone Number:*

Corporate Fax:

Customer Attention:

Is your shipping address the same?

Yes

Shipping Address:

City:

State:

Zip Code:

Country:

Phone:

Accounts Payable Contact:*

Email:*

Phone:*

Ext:

Bank Name:

Contact Phone:

Billing Currency:

Trade References (Minimum of 3):

Max. file size: 50 MB.

I agree that the attached form does not contain sensitive financial information.

Requested Credit Limit:

Expected Order Value:

This form must be completed and signed by authorized company representative. The undersigned hereby applies to MIRATECH Group for credit.*

It is understood and agreed that the undersigned consents to MIRATECH Group investigating the applicant’s credit history for the purpose of extending credit.

Our terms do not extend beyond 30 Days. Payments not received within our terms may cause restriction of credit.

There will be a 1 ½% per month finance charge at an annual rate of 18% on all past due invoices.

I have read and agree to the Terms and Conditions as listed above.

Customer Signature*

Printed Name:*

Title*

Date*

Comments

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