Credit Application

Corporate Name (associated with DUNS number):

ACCURACY OF THE LEGALLY FILED NAME & ADDRESS IS CRITICAL TO THE CREDIT PROCESS SPEED

DBA(if applicable):

Yes

No

DBA:

Line of credit requested($):

Phone

Corporate address:

Street Address

Address Line 2

City

State/Region/Province

Postal / Zip Code

Country

(associated with DUNS number)

Legal address is different than corporate address?

Yes

No

(Required for billing PO)

Legal address:

Street Address

Address Line 2

City

State/Region/Province

Postal / Zip Code

Country

(Required for billing PO)

DUNS #:

Attach file(s):

Attach 3 trade references.

AP contact:

First Name

Last Name

Email

Phone

Purchasing contact:

First Name

Last Name

Email

Phone

Number of employees:

Annual sales:

Are purchases taxable, non-taxable, or per order?

If non-taxable, please provide the tax exempt information below and tell us if your tax status may change from order to order (per-order).

Attach file:

Attach tax exempt form.

Arizona based organizations must complete and sign AZ form 5000 AZFORM5000.PDF Colorado based organizations only need to provide valid CO sales tax license #. New Mexico based organizations must provide a valid NTTC certificate.

Any misrepresentation in this application will be considered evidence of fraud, since this information is the basis for the extending of credit. As an inducement to grant credit, the undersigned warrants that the information submitted is true and correct. You are authorized to investigate the credit references listed.

In consideration for the extension of credit, said business promises to pay In-Position Technologies, LLC (dba IP Tech) for all purchases within the term agreed and agrees to pay a service charge per month of 1.5% per month (18% annual percentage rate) on all past due balances. In the event any third parties are employed to collect any outstanding monies owned by said business, the undersigned agrees to pay the collection costs, including attorney fees, whether or not litigation has commenced, and all costs of litigation incurred. The undersigned represents that he/she has the authority to execute this credit agreement on behalf of the business identified.

Name

First Name

Last Name

Title

Date

dd-MMM-yyyy

Signature

In-Position Technologies AP Information Form

ATTACH 3 TRADE REFERENCES