Name
*
First Name
Last Name
Business Name
*
Email
*
Office Phone
(###)
###
####
Cell Phone
*
(###)
###
####
Fax Number
Physical Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Sales Tax Exemption Number
*
What location will you be ordering from
Springfield, MO
West Plains, MO
Independence, MO
Columbia, MO
Jefferson City, MO
Batesville, AR
Springdale, AR
Little Rock, AR
Topeka, KS
Newton, KS
Omaha, NE
Person(s) Authorized to Charge
*
Accounts Payable Contact
*
First Name
Last Name
Years in Business in present form
*
Form of Business (Select one)
*
Corporation
Partnership
Sole Proprietorship
Banker/ Bank Contact
*
First Name
Last Name
Bank Phone
*
(###)
###
####
Bank Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Account #
*
Permission for release
*
I hereby give the above listed
financial institution my permission to release any and all
information concerning my credit status to ColorVision Corporation
Date of Submission
*
MM
DD
YYYY
Signed on this notated date,
*
Signature of Account Holder
First Name
Last Name
Credit / Trade Reference 1
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Credit / Trade Reference 2
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Credit / Trade Reference 3
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Check
*
I certify that all information on this form is correct. I/we fully understand ColorVision Corporation's credit terms of Net 30 and a 1.5% per month service charge may apply to any/all non-current balances and agree to pay in accordance with these terms. Should collection procedures become necessary I agree to pay all attorney fees. In consideration of ColorVision Corporation extending credit hereunder, the undersigned, jointly and severally, and unconditionally guarantee and promise to pay, on demand, any and all indebtedness of the above named applicant to ColorVision Corporation.
Signature
*
First Name
Last Name
Title
*
Date of Submission
*
MM
DD
YYYY
Principal(s) Information
*
First Name
Last Name
Title
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Communications
*
I agree to let ColorVision communicate with me via email and send exclusive content on promotionals, products, industry news, and more!
Thank you for your interest in an account with ColorVision!
We are looking forward to working with you and will be in touch shortly.
