Credit Application

You may use this form as a credit application or use your standard form and return by fax with your order. New accounts should include full credit information with at least three trade references and complete company information including purchasing and user contact information. Please fax back to Analyticon with purchase order. (973-379-6795).

COMPANY INFORMATION

Company Name:__________________________________________________________

User/Requestor Name:_____________________________________________________

Phone:____________________________ FAX: _________________________________

Purchasing Agent Name:____________________________________________________

Phone:____________________________ FAX: _________________________________

Billing Address:___________________________________________________________

_______________________________________________________________________

Shipping Address: _______________________________________________________________________

_______________________________________________________________________

Billing Instructions:_________________________________________________________

Years in Business:________ No. of Employees:______D&B #:_______________________

Company Web Site _______________________________________________________

If Subsidiary- Name of Parent Co.______________________________________________

Address of Parent Co.______________________________________________________

Authorized Buyer(s):________________________________________________________

Name & Title: ____________________________________________________________

BANK INFORMATION:

Bank Name:_________________________________Phone:_______________________

Address:________________________________________________________________

Account #:_____________________Officer to Contact:____________________________

Type of Account:__________________________________________________________

TERMS OF SALE

1.) Our standard terms are net 30 Days.
The net due date is calculated from the date of invoice. A 1.5% charge will be added per month when not paid within 30 days.

2.) Should Applicant default in payment of the outstanding account for monies that are legitimately owed, then Analyticon Instruments shall be entitled to incur expenses for the cost of collection and reasonable attorney's fees, which amount shall be added to the unpaid balance of applicants account and shall be due and owing to Analyticon Instruments Corp.

I hereby certify that the information set forth here, together with all other information submitted in connection with this application is true and correct.
I understand that Analyticon Instruments Corporation will rely on this information in extending credit to me.
I have read and understand the Terms of Sale and agree that such terms apply to all transactions with Analyticon Instruments Corporation.

BANK AUTHORIZATION. Signature authorizes you to release information regarding our account to Analyticon Instruments Corporation for the purpose of establishing credit.

I also certify that I have the authority to release such corporate information.

Signature:____________________________Print:_______________________________

Title:________________________________Date:______________________________

TRADE REFERENCES:

Please include standard company credit information complete with trade references. Use seperate page and include phone number(s) and account number(s)