A1 Servo Motor Repair 888-336-8430

Forms

Credit Application Optional PDF format (Print & Fax)pdficon.gif - 426 Bytes     

Thank you for taking time to complete an application for credit. Our terms are Net 30. If no credit is established, our terms are C.O.D or Credit Card Only (American Express, MasterCard, Visa or Discover).
Prior to submitting, ensure all items in 'red' are not blank.

Date:
Company Name:
Address:
City:
State:
Zip:
Phone Number:
Fax:
E-mail:
First Name:
Last Name:
Business Structure:
Corporation Division Subsidiary
Partnership Owner
Federal ID Number:
Number of years in business:
Dun & Bradstreet Number:
Product Line:
Bank Reference:
Bank Name:
Address:
City:
State:
Zip:
Account No.:
Officer:
Fax Number:

Trade References (please provide 3):

Name:
Address:
City:
State:
Zip:
Fax Number:

Name:
Address:
City:
State:
Zip:
Fax Number:

Name:
Address:
City:
State:
Zip:
Fax Number:

I hereby certify that the information in this credit application is correct. The information included in the credit application is for use by A-1 Servomotor Repair in determining the amount and conditions of credit to be extended. Further, I hereby authorize the bank and trade references listed in this credit application to release the information necessary to assist A-1 Servomotor Repair in establishing a line of credit for my company.

Submitted by:
Title:
Signature:

not required for on-line application