[credit application]


To Download our Credit Application please click on the Following PDF links:

US — CDN

Or Print out the following form and fax it back to us at +1-604-543-7354

ANALYTIC SYSTEMS
"Power Conversion Solutions"
#207 12448 82nd Avenue
Surrey, B.C., Canada, V3W 3E9
tel: 1-604-543-7378, fax: 1-604-543-7354

CUSTOMER CREDIT APPLICATION

Instructions:

1. Print out and fill in this fax order form completely.
2. Fax the form to Analytic Systems at +1-604-543-7354.
3. A representative of Analytic Systems will contact you as soon as possible, via the communications method you indicate below, to confirm your application and process your information.

Confidential Information


Company Name_____________________________________________________________
Date_____________
Address___________________________________________________________
City, State, Zip _____________________________________________________ Type _ Sole Proprietorship
phone_no No. ________________________ of _ Partnership
Fax No. _____________________________ Business: _Corporation
_ Subsidiary
Sales Volume $ ___________ Credit Line Requested: $ ___________ _ Division
Nature of Business ______________________________________________ No. of Employees ________

US – FID/EIN # ___________________

Canada – Business # ______________

 No. of Years in Business___________
Credit Card # _____________________________________ Exp _____________
Type: Amex ____ MC ___ Visa ___

Billing Address if different than above: ________________________________________________________________________

I am an authorized signer on the above credit card and hereby give my permission to bill the credit card when verbally requested

Card Holder Name ________________________________
Signature: ________________________________________

Net 30 Day Terms, credit card needs to be on file
Credit Requested $ __________________
Credit Card Purchases

 
TERMS OF SALE SHALL BE 30 DAYS


Ownership: 		 
Name: Phone #:
Address:  
Name: Phone #:
Address:  

Trade References:
Name: Fax #: Phone #:
Address:
Name: Fax #: Phone #:
Address:
Name: Fax #: Phone #:
Address:
Name: Fax #: Phone #:
Address:

Bank Reference:
Name: Acct #: Phone #:
Address:

All Statements made herein are true and accurate to the best of our knowledge. We authorize Analytic Systems Ware (1993) Ltd. to make any and all inquiries necessary for action on this credit application. We hereby indemnify Analytic Systems Ware (1993) Ltd. and its agents, from any liability resulting from their credit survey.

Authorized Signature ______________________________________

Name & Title (Print or Type) _________________________________

 

— END OF CREDIT APPLICATION — PLEASE FAX TO 1-604-543-7354 —