CREDIT APPLICATION FORM - Free Template Downloads



BioFire Diagnostics Distributor Credit Application FormPlease fill out this application completely and return it to our accounts managerPlease Submit Application to: Email:newaccounts@Fax:(801) 588-0507Phone:(801) 736-6354General Business Information (Complete all fields.)Legal Business NameParent/Affiliated Companies (if applicable)Business Name: FORMTEXT ?????Business Name: FORMTEXT ?????Street Address: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Web Address: FORMTEXT ?????Web Address: FORMTEXT ?????Federal Tax ID #: FORMTEXT ????? Dun & Bradstreet ID #: FORMTEXT ????? DBA, if any: FORMTEXT ????? VAT#, if any: FORMTEXT ?????(Note: If applicable, copy of reseller or tax exemption certificate required.)Type of Business: FORMCHECKBOX Individual FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX Govt. Agency FORMCHECKBOX Other ______________________________ FORMCHECKBOX Public FORMCHECKBOX Private FORMCHECKBOX Public Univ/Coll FORMCHECKBOX Private Univ/CollYears in Business: FORMTEXT ????? Year of Inc.: FORMTEXT ????? State of Inc: FORMTEXT ????? Credit Requested $: FORMTEXT ????? Terms (Net 30 standard): FORMTEXT ?????Are Purchase Orders Used? FORMCHECKBOX Yes FORMCHECKBOX NoName of person responsible for purchasing: FORMTEXT ????? Telephone: FORMTEXT ????? Email: FORMTEXT ? ????Name of person responsible for accounts payable: FORMTEXT ????? Telephone: FORMTEXT ????? Email: FORMTEXT ??? ??Name of Owners, Partners, or Officers and Titles if Incorporated (Complete all fields and provide at least one owner, partner or officer.)Name: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Title: FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Email: FORMTEXT ?????Email: FORMTEXT ?????Distributor Trade Reference Information (Please provide information of at least three companies you represent / distribute for.)Name: FORMTEXT ?????Name: FORMTEXT ?????Contact Person: FORMTEXT ?????Contact Person: FORMTEXT ?????Address: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Email: FORMTEXT ?????Email: FORMTEXT ?????Account #: FORMTEXT ?????Account #: FORMTEXT ?????Name: FORMTEXT ?????Name: FORMTEXT ?????Contact Person: FORMTEXT ?????Contact Person: FORMTEXT ?????Address: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Email: FORMTEXT ?????Email: FORMTEXT ?????Account #: FORMTEXT ?????Account #: FORMTEXT ?????Distributor Bank Reference Information (Complete all fields and provide at least one reference.)Bank Name: FORMTEXT ?????Bank Name: FORMTEXT ?????Contact Person: FORMTEXT ?????Contact Person: FORMTEXT ?????Address: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Phone #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Fax #:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Email: FORMTEXT ????? Email: FORMTEXT ?????Checking Acct #: FORMTEXT ?????Checking Acct #: FORMTEXT ?????Savings Acct #: FORMTEXT ?????Savings Acct #: FORMTEXT ?????Loan Officer: FORMTEXT ?????Loan Officer: FORMTEXT ?????Loan #: FORMTEXT ?????Loan #: FORMTEXT ?????This application is submitted for the purpose of obtaining credit with BioFire Diagnostics, Inc. and is warranted to be true. By signing this application the undersigned acknowledges that he/she is authorized to execute this application and to obligate the company to make payment in full for all amounts due according to invoice on or before the net due date. Additionally, the undersigned will be responsible for all collection costs and attorney fees, with or without lawsuit, in order to collect any delinquent moneys. The undersigned hereby authorizes BioFire Diagnostics, Inc., Incorporated to make such inquiries (corporate/personal) as are necessary to obtain credit information and authorizes the bank(s) of record to release information regarding accounts.Signature of Authorized Owner, Partner or Corporate Officer Required.Please include current financial statements. Personal financial statements for all owners/officers must be furnished for companies in existence less than two years. Upon credit approval, the undersigned agrees to terms of NET 30 DAYS.Signature of Owner, Partner or Corporate OfficerDate FORMTEXT ?????Printed Name of SignerTitle FORMTEXT ????? FORMTEXT ?????BioFire Diagnostics Distributor Blanket Sales Tax Exemption CertificatePlease fill out this application completely and return it to our accounts manager(MULTI-JURISDICTION)Please Submit Application to: Email:newaccounts@Fax:(801) 588-0507Phone:(801) 736-6354Issued to:BioFire Diagnostics, Inc.390 Wakara WaySalt Lake City, Utah 84108126301521272500*Name of Firm (Buyer): FORMTEXT ?????198691521463000*Street Address or P.O. Box Number: FORMTEXT ?????35966402165350032004021653500250126521653500*City: FORMTEXT ?????*State: FORMTEXT ?????*Zip: FORMTEXT ?????*Buyer is Engaged as a Registered: FORMCHECKBOX Wholesaler FORMCHECKBOX Retailer FORMCHECKBOX Lessor FORMCHECKBOX Manufacturer255841514414500 FORMCHECKBOX Other: FORMTEXT ?????and is registered with the below listed state(s) where your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product to be resold, leased ore rented in the normal course of our business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following: State Registration # State Registration # State Registration #AL FORMTEXT ?????729615381000AR FORMTEXT ?????729615-381000AZ FORMTEXT ?????729615-190500CA FORMTEXT ?????729615000CO FORMTEXT ?????729615190500CT FORMTEXT ?????729615-571500DC FORMTEXT ?????729615635000FL FORMTEXT ?????729615-127000GA FORMTEXT ?????72961563500IA FORMTEXT ?????729615190500ID FORMTEXT ?????729615254000IL FORMTEXT ?????729615317500IN FORMTEXT ?????729615381000KS FORMTEXT ?????729615444500KY FORMTEXT ?????729615-44450072961514351000LA FORMTEXT ?????MA FORMTEXT ?????MD FORMTEXT ?????ME FORMTEXT ?????MI FORMTEXT ?????MN FORMTEXT ?????MO FORMTEXT ?????MS FORMTEXT ?????NC FORMTEXT ?????ND FORMTEXT ?????NE FORMTEXT ?????NJ FORMTEXT ?????NM FORMTEXT ?????621030-31178500621030-46990000621030-62865000621030-77787500621030-94615000621030-109537500621030-125412500621030-141287500621030-157162500621030-17208500062103061404500621030466090006210303181350062103016065500621030317500621030-15430500NV FORMTEXT ?????NY FORMTEXT ?????OH FORMTEXT ?????OK FORMTEXT ?????PA FORMTEXT ?????RI FORMTEXT ?????SC FORMTEXT ?????SD FORMTEXT ?????TN FORMTEXT ?????TX FORMTEXT ?????UT FORMTEXT ?????VA FORMTEXT ?????VT FORMTEXT ?????WA FORMTEXT ?????WI FORMTEXT ?????WV FORMTEXT ?????331470-31178500331470-46990000331470-62865000331470-77787500331470-94615000331470-109537500331470-125412500331470-141287500331470-157162500331470-17208500033147016065500331470317500331470-15430500WY FORMTEXT ?????(*) We will need a copy of each State Certificate attached with this application.I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax, we will pay the tax due direct to the proper taxing authority when state law so provides or informs the seller for added tax billing. This certificate shall be part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until cancelled by us in writing or revoked by the state.General Description of Products to be Purchased from Seller: FORMTEXT ?????-3810952500 FORMTEXT ?????-38101143000Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.*Authorized Signature:13011151143000*Title: FORMTEXT ?????*Date: FORMTEXT ?????BioFire Diagnostics Distributor Authorization to Release Credit InformationPlease fill out this application completely and return it to our accounts managerPlease Submit Application to: Email:newaccounts@Fax:(801) 588-0507Phone:(801) 736-6354In consideration of an open account arrangement with BioFire Diagnostics, Inc., I hereby authorize you to release information to BioFire Diagnostics, Inc. regarding credit history, checking and savings accounts, and/or loan experience. Thank you for your cooperation.Legal Name of CompanyDBA, if anyAuthorized SignatureTitleDate ................
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