Credit Application Form

	Date
Legal Company Name
Billing Address
Physical Address (if different)
Telephone
Fax
Type of Business
Website URL
Email Address

Number of Years in Business
Proprietorship Partnership Corporation Date Incorporated
State of	Federal Tax ID

Owner(s), Partner(s) or Corporate Officers
Title
Title
Title

Registered Agent
Address
Accounts Payable Manager
Authorized Purchasers
Special Billing Instructions

Purchase Order Required? Yes No	Amount of Credit Desired

Bank References

Bank Name
Address
Bank Officer
Telephone
Primary/Operating Account #
Customer Service

Trade References

Name		Office Use Only Bank High Days
Telephone
Address
Fax

Name
Telephone
Address
Fax

Name
Telephone
Address
Fax

Name
Telephone
Address
Fax

I hereby certify that all information included in this application is complete and true to the best of my knowledge and I authorize all references, or agents thereof, to release all pertinent information as requested by Illuminations Lighting Design. I also understand that, according to Illuminations Lighting Design's terms, payment on all invoices is due upon receipt and that the initial order may require a deposit or prepayment and that applicable liens may be applied.

Printed Name
Title
Your initials Here
Date

Credit Application Form

Phantom Lighting System

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