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PLEASE TYPE OR PRINT LEGIBLY
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_________________
Date
___________________________________
Firm Name
___________________________________
Billing Address
___________________________________
City, State, Zip
___________________________________
Telephone Number
___________________________________
Fax Number
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___________________________________
Shipping Address (if different from billing address):
___________________________________
___________________________________
___________________________________
E-mail Address
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__________________
Date business commenced
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____________________
How long at present address?
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___________________________________
Name(s) of Principal
___________________________________
Address of Principal
___________________________________
$__________________________________
Amount of credit requested
Which division will you primarily be using?
____ Consumer & Commercial Products
____ Automotive
____ Communications
Purchase orders required? ____ Yes ____ No
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___________________________________
Former address (if any)
___________________________________
Type of business you will be doing with United Radio, Inc.
NY State Customers:
Sales Tax Exempt? ____ Yes ____ No
If Yes, a resale certificate must be attached.
Type of Organization:
____ Individual Ownership
____ Partnership
____ Corporation _________ Date Incorporated
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***References are required for all net 30 accounts***
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Trade Reference 1
___________________________________
Firm Name
___________________________________
Address
___________________________________
City, State, Zip
___________________________________
Phone Number
Fax Number
___________________________________
Account Number
Terms
___________________________________
Contact Name
Trade Reference 3
___________________________________
Firm Name
___________________________________
Address
___________________________________
City, State, Zip
___________________________________
Phone Number
Fax Number
___________________________________
Account Number
Terms
___________________________________
Contact Name
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Trade Reference 2
___________________________________
Firm Name
___________________________________
Address
___________________________________
City, State, Zip
___________________________________
Phone Number
Fax Number
___________________________________
Account Number
Terms
___________________________________
Contact Name
Bank Reference
___________________________________
Firm Name
___________________________________
Address
___________________________________
City, State, Zip
___________________________________
Phone Number
Fax Number
___________________________________
Account Number
Terms
___________________________________
Contact Name
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Confirmation of Information Accuracy and Release of Authority to Verify
I hereby certify that the information in this credit application is correct. The information included in this credit application is for use by United Radio, Inc. in determining the amount and conditions of credit to be extended. I understand that United Radio, Inc. may also utilize other sources of credit which it considers necessary in making this determination. Further, I hereby authorize the bank and trade references listed in this credit application to release the information necessary to assist United Radio, Inc. in establishing a line of credit.
_________________________________________________
Signature
___________________________________
Title
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___________________________________
Date
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Terms: MasterCard, Visa or Company Check until credit application is authorized. Approved accounts: Net 30.
Federal ID#: 16-0906884
Office use only:
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References Checked by _________
Credit Approved by _________
Amount Approved _________
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Customer # _________
New Customer Letter _________
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