Credit Request Form

Please complete the following.

Applicants Trading Name:

Address:

Contact:

Telephone: Fax:

E-Mail:

Web:

Nature of Business:

Established: Subsidiary:

Names and addresses of Directors:

Currency:  £ $ DM Fr Li Euro Pts kr IR£ Esc SFr Monthly Limit Required: 999 1000-2499 2500-4999 5000-9999 10000+

Bank Details:

Bank Name:

Address:

Account Name:

Account Number:

Line of Credit:

Trade References:

1. Name:

Address:

Telephone: Fax:

Contact:

E-Mail:

Years Account Held: 1 2 3 4 5+

2. Name:

Address:

Telephone: Fax:

Contact:

E-Mail:

Years Account Held: 1 2 3 4 5+

Resale Tax Certification

         The undersigned company or individual (purchaser) hereby certifies that all tangible personal property purchased from Ep-tech, Inc. will be resold, rented, or leased by Purchaser within the geographical limits of the United States of America, its territories and possessions, in its present form or attached to other personal property to be sold, and is therefore exempt from the sales and use tax laws of the state or states in which the purchaser resides or is otherwise entitled to do business.    

         Purchaser  understand that if Purchaser makes any use of the items other than retention, demonstration, or display while holding it for sale , lease, or rental, Purchaser must pay any applicable sales or use tax on the item of use based upon either the purchase price or the fair-market rental value for the period of time used.

         The undersigned Purchaser further certifies that , if the tangible personal property purchased under the exemption certificate is used for any purpose other than resale or rental, and would subject such personal property or service to either a sales or use tax, the undersigned will report and pay the applicable tax to the appropriate sales and/or use tax authority and hold Ep-tech, Inc., harmless for said tax and from all expenses connected therewith.                 

Company Name:         Sales Tax Number:

Address:     Telephone:  

Signature:  ________________________________  Date:_____/_____/________

Preferred Payment Method: COD Company Check:      Postdate check:     Net Terms:

Comments:

I (We) hereby certify that the information provided on this document is correct and true. Therefore, I (We) agree to comply with these terms. We authorize Ep-Tech, Inc., to contact any references in order to establish our credit with their company . Ep-Tech, Inc. will charge $20.00 for each check returned. The payment or accrual of interest does not extend terms or defer payment of any past due invoice. Interest will occur on  all invoices considered past due by the terms extended to me (us) at the rate of 18% per annum. If collection or attorney fees are necessary, the customer will be held liable for all charges, all quotations, orders, and solicitations are not deemed accepted until approved by Ep-Tech, Inc. Authorized Management. 

For any refused shipments incurred the customer will be held liable for all freight charges.

Name:                           AUTHORIZED SIGNATURE

Title:               Signature:  ______________________________ Date:____/____/______

PERSONAL GUARANTEE

I (We) do hereby agree to bind myself personally to any and all obligations extended to the above referenced application business, herein referred to as "Company".  As collateral, I (We) will extend to Ep-Tech my  (our) personal guarantee that any and all sums of indebtedness made by "Company" that are not paid by the terms extended to " Company", will be paid by me personally. It is understood and and agreed that all merchandise received shall be inspected and returned to Ep-Tech, Inc. for replacement within terms of Ep-Tech, Inc's  policy. 

Name:         

Signature:  ________________________________  Date:_____/_____/________

Home Address:   Social Security No.:

    Please Print, sign, and fax form -  fax (847) 228-5479