Terms Application

Business and Credit Info

Accounts Payable First Name *

Accounts Payable Last Name *

AP Phone *

AP Fax

AP E-mail *

Company to Bill Address *

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Country *

Bank Name *

Branch Name *

Branch Contact

Bank Branch Phone Number *

Bank Address *

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Country *

General Information

Federal Tax ID # *

Dun & Bradstreet #

Amount of Credit Requested *

Are Purchase Orders Required? *

Yes No

Checking Acct. # *

Checking Acct. Routing # *

Savings Acct. # *

Savings Acct. Routing # *

Authorization to Release Confidential Information *: I/We authorize you our financial institution to release all information related to these accounts, accounts balances and activity to CTIconnect, LLC.

Authorization Signature *

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Business References

Reference 1

Reference 1: Company Name *

Contact Name *

Type of Account

Phone Number *

Fax Number

E-mail

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code

Country

Reference 2

Reference 2: Company Name *

Contact Name *

Type of Account 2

Phone Number 2 *

Fax Number 2

E-mail 2

Street Address 2 *

Street Address Line 2

City *

State / Province *

Postal / Zip Code

Country

Terms and Conditions

All accounts are Cash/COD/Wire/Credit Card until a credit application has been completed, reviewed and approved. If any indebtedness incurred pursuant to this request for credit is not paid in full when due, the undersigned agrees to pay all costs of collection, including a reasonable attorneys fee. Any balance so remaining unpaid shall bear interest at the lesser rate of 1.5% per month or the maximum rate permitted by applicable law, until paid in full.

All invoices are to be paid 30 days from the date of the invoice. *

Claims arising from invoices must be made within 7 business days of the invoice date. *

By submitting this credit application, indicates your acceptance of the terms and conditions as stated and terms of service listed at cticonnect.com. In addition, you authorize CTIconnect, LLC. To make any and all inquiries necessary to process this credit application. *

Agreed and Accepted, Signed *

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Today's Date *

Credit Application for Net 30 Terms

Company Information

Business and Credit Info

General Information

Business References

Terms and Conditions

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