Net 30 Terms Order Form – Fill Out and Use

Name:__________________________________________________

Date:______/______/__________

Division:_________________________________________________

Year Established:____________

Years at this address:________

Physical Address:__________________________________________

(If less than 2 years, please provide previous

Company

address on separate page)

or

City/State/Zip:____________________________________________

Web site:____________________

Individual

Applying

Phone: (

)________________________Ext._____________

@__________________________

for Credit

Fax: (

)____________________________

Accounts Payable Contact:

Purchasing Contact:_________________________________________

Phone: (

)_______________

Billing Address:_____________________________________________

Email:_______________________

City/State/Zip:______________________________________________

@__________________________

Phone: (

)__________________Fax: (

)_________________

Please Provide Pertinent Company Information below:

Resale: _____No _____Yes

Classification:

(Held strictly confidential)

Business Credit References: (Please provide at least two

Resale#

___Individual

businesses, including phone, fax and contact name)

NOTE: A Signed CA Resale Certification is

required for our files.

___Partnership

D&B #

___Corporation

________________________

___Government

___AA Distributor

Vendor #

___Sole

(If assigned by your company)

Proprietorship

_______________________

Bank Information:

Please Note:

Typical

Bank Name:____________________________________

Account#:____________________________

Processing Time

for Credit

Address:__________________________________ City/State/Zip:_____________________________

Applications

Fax: (

)_____________________________ Fax: (

) _____________________________

is 48 hours.

I certify that the information herein is true and correct.

VERIFICATION:

I fully understand that Anaheim Automation’s Terms are

RETURN BY FAX:

(Do not fill out this box)

strictly Net 30 Days.

___Agree to comply to Terms

(714) 992-0471

___Checked Bank

Print Name:

or

Mail to address

___Checked D&B

______________________________________________________________

___Checked References

listed below

___CREDIT APPROVED

Signature:__________________________________ Date: ______________

Attn: Accts. Rec.

___CREDIT DENIED