LPC TECHNOLOGY

20286 CARREY RD.   WALNUT, CA   91789 TEL: (909) 598-1266  FAX: (909) 598-2710

CREDIT APPLICATION

 

APPLICATION FOR: OPEN ACCOUNT             COD COMPANY CHECK

 

REQUESTED CREDIT LIMIT $____________________

 

COMPANY INFORMATION

COMPANY NAME

 

TEL:

FAX:

RESALE/SALES TAX # REQUIRED

STATE OF INCORPORATION

SUBSIDIARY OF (IF APPLICABLE):

 CORPORATION

BILLING ADDRESS

CITY

STATE

ZIP

 PARTNERSHIP

SHIPPING ADDRESS

CITY

STATE

ZIP

 PROPRIETORSHIP

ACCOUNTS PAYABLE CONTACT & TELEPHONE #

 

SOLE PROPRIETOR OR ONE PARTNER’S NAME

ADDRESS

HOME PHONE:

SOCIAL SECURITY #

 

BANKING INFORMATION

1ST BANK  NAME

ADDRESS

CITY

STATE

ZIP

TEL:

FAX:

CHECKING ACCOUNT NUMBER

SAVINGS ACCOUNT NUMBER

2ND BANK  NAME

ADDRESS

CITY

STATE

ZIP

TEL:

FAX:

CHECKING ACCOUNT NUMBER

SAVINGS ACCOUNT NUMBER

 

TRADE INFORMATION

1ST COMPANY NAME

ADDRESS

CITY

STATE

ZIP

TEL:

FAX:

ACCOUNT NUMBER

CONTACT NAME

2ND COMPANY NAME

ADDRESS

CITY

STATE

ZIP

TEL:

FAX:

ACCOUNT NUMBER

CONTACT NAME

3RD COMPANY NAME

ADDRESS

CITY

STATE

ZIP

TEL:

FAX:

ACCOUNT NUMBER

CONTACT NAME

*PLEASE INCLUDE A COPY OF A  VOID COMPANY CHECK

 

I hereby authorize lpc technology to request information from the above references.

 

SIGNATURE_________________________________________DATE____________

 (AUTHORIZED SIGNATURE)

­­ LPC TECHNOLOGY

20286 CARREY RD.   WALNUT, CA   91789 TEL: (909) 598-1266  FAX: (909) 598-2710

 

_____________________________ (reseller) hereby certifies that it holds valid state sales tax permit number ___________________  issued by the state of _______________; that it is engaged in the business of selling __________________; and that tangible personal property described below purchased from LPC Technology will be resold and is not held by reseller for retention, demonstration, or display for sale in the regular course of reseller’s business.  Reseller will report the purchase of such property to the appropriate tax authorities and will pay required sales and use taxes relating to the purchase of such property.

 

SIGNATURE___________________________ DATE________________

PRINT NAME__________________________ TITLE_________________

ADDRESS______________________ CITY____________ STATE ____ ZIP____

TELEPHONE_________________________ FAX________________________

 

 

 

REQUEST FOR VERIFICATION OF DEPOSIT

COMPANY NAME

 

TEL:

FAX:

ADDRESS

CITY

STATE

ZIP

COMPANY NAME

 

TEL:

FAX:

ADDRESS

CITY

STATE

ZIP

I  HEREBY AUTHORIZE TO RELEASE THE INFORMATION

SIGNATURE

DATE

FROM BELOW TO LPC TECHNOLOGY INC.

PRINT NAME

TITLE

 

 (FOR BANK USE ONLY)

 

1ST BANK  NAME

ADDRESS

CITY

STATE

ZIP

TEL:

FAX:

CHECKING ACCOUNT NUMBER

SAVINGS ACCOUNT NUMBER

2ND BANK  NAME

ADDRESS

CITY

STATE

ZIP

TEL:

FAX:

CHECKING ACCOUNT NUMBER

SAVINGS ACCOUNT NUMBER

CURRENT BALANCE

AVERAGE BALANCE

DATE OPENED

NSF CHECKSYES   NO

SIGNATURE

TITLE

DATE