Specifications

Please print or type and complete all sections fully.
Business Name_______________________________________________________ Telephone___________________________
Address__________________________________________________________________________________________________
City________________________________________ State/Prov_____________ Country________________________________
Web Site(URL)______________________________
Business Type: □ Sole Proprietorship □ Partnership □ Corporation
Incorporated in the state/country of__________________________
How many years in business under the name listed above?____________ Annual revenue last year:______________________
What is your rating (if known) by Dun & Bradstreet:_______________________________
Federal ID#:_________________________ If tax exempt, please attach completed resale certificate.
Amount of credit requested (in U.S. Dollars):____________________________
CONTACTS
ACCOUNTS PAYABLE:
__________________________________________________________ ___________________ _______________________
Name/Title Phone Email
Corporate Officer / Senior Manager:
__________________________________________________________ ___________________ _______________________
Name/Title Phone Email
BANK / TRADE REFERENCE INFORMATION
Bank:_______________________________________________________________ Tel#_________________________________
Full Address:______________________________________________________________________________________________
Account#_______________________________ Bank Contact Name ________________________________________________
TRADE CREDIT REFERENCES (PLEASE SUPPLY FULL NAME & COMPLETE ADDRESS)
Company Name Contact Address Phone
1)________________________________________________ _________________________________ _________________
2)________________________________________________ _________________________________ _________________
3)________________________________________________ _________________________________ _________________
We hereby authorize the above listed credit references to release information to Masterclock, Inc. for use in the evaluation of this request. On behalf
of the applicant, the undersigned hereby warrants that the above information be true, correct and complete. All sales are subject to the Masterclock
terms & conditions on file at Masterclock offices and available to all applicants. Note that Masterclock will automatically add sales tax to shipments
sent to Missouri addresses or companies incorporated in Missouri.
I hereby certify that I am authorized to sigh and submit this application for and on behalf of the company named above.
Signature_________________________________________________
Name_______________________________________________________ -Title __________________ Date ______________
(please print)
CUSTOMER REQUEST FOR CREDIT
This is a request for net 30 days credit from date of shipment.
We understand and agree that if payment is not received by
Masterclock within 30 days of shipment date then a 1.5%
charge will be added for each month or part thereof that the
payment is late.
For Masterclock, Inc. Corporate office use only
Date Received______________
References Checked/Credit Report Run By:___________ Credit Approved/ Denied by:__________ Credit Limit:__________
Notes ______________________________________________________________________________________________
© 2005, Masterclock, Inc Confidential rev: 8/2006