Trade Name    DBA
Parent Company
Address
City, State, Zip
Telephone # Fax #
Date Business Established Dun & Bradstreet # Rating
Estimated annual sales Approximate number of employees
Business is a: Corporation Partnership Sole Proprietorship           Federal Tax #
AMOUNT OF CREDIT REQUESTED:
Is your business sales tax exempt?   Yes     No      If yes: Tax Exempt Number

Names of Principal Officers, Partners, or Proprietors:
Name Title
Name Title
Accounts Payable Contact   Phone

Bank References:

Name
Address
City State Zip
Account #
Phone: Fax:
Contact Name

Trade References: Please provide the information from your major suppliers.
Note: Fax numbers are required

Name
Address
City State Zip
Account #
Phone: Fax:
Contact Name

Name
Address
City State Zip
Account #
Phone: Fax:
Contact Name

Name
Address
City State Zip
Account #
Phone: Fax:
Contact Name

Buyer agrees to notify Connectronics immediately upon change of ownership, address or phone number. If granted credit by Connectronics, Buyer agrees to pay all invoices according to terms. Buyer understands that any false or misleading statements in this application may cause any extension of credit to be in default. Buyer also agrees and promises to pay a 1.5% finance charge per month on all past due balances. By my signature below, I (hereby) authorize the bank and trade references listed in this credit application to release the information necessary to assist Connectronics in establishing a line of credit.

Name             Title

Fax or send this document to:
Connectronics
Attn:  I am working with: Austin Chris Duane Justin Kurt Logan Manny Michael Paul Tad (required-  if a name is not selected, this application will not be processed)
234 33rd St. Dr. S.E.
Cedar Rapids, IA 52403
Phone: (319)366-4971
Fax: (319) 366-8545                                                                    

Please contact me as soon as possible regarding this matter.