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ePaper created 2015-06-23, 16:53:42 | version 1.33.0
Merrimack Media 350 3rd Street., #1704, Cambridge, MA 02142 www.merrimackmedia.com ORDERS: 855-631-1478 • FAX: 877-585-1049E-MAIL: orders@merrimackmedia.com CREDIT APPLICATION Company Name: _____________________________________________________ Contact: _____________________________________________________ Billing Address: _____________________________________________________ City: ________________________ State: _____________ Zip Code: ____________ Shipping Address: _____________________________________________________ City: ________________________ State: _____________ Zip Code: ____________ Phone: _________________________ FAX: __________________________ E-mail: _____________________________ Type of Business: ____________________________ In Business Since: __________ Form of Business: [ ] Corporation [ ] LLC [ ] Partnership [ ] Sole Proprietor Is a Purchase Order required? _________ Name of individual with authorization: ____________________________________ If it is to be a blanket PO, please list the number and expiration date. Number ____________________ Expiration Date ________________ To whose attention should invoices be sent? __________________________________ Is your work taxable? ____ If not, please attach signed certificate and list your tax exempt or resellers number: ___________________________ If you which to pay by credit card, please provide information below: Card Number __________________________________ Exp. Date __________Three digit code_______ Type of card: Visa__________Mastercard__________Other (specify)_____________________________ Bank References (please list name and address of local banks): _____________________________________________________ _____________________________________________________ _____________________________________________________ Trade References (Please list name, address, phone number, and account number of three references. Do not list credit cards. _____________________________________________________ _____________________________________________________ _____________________________________________________ Our terms are net 30 days. Accounts not paid in this time frame will be charged 1.5% interest rate per month and future orders will be on a C.O.D. basis until the account is current. Should collection or legal action be required to collect past dues, fees for such action will be added to your account. Print Name: ____________________________________________________________ Title: __________________________ Signed by: ______________________________________________________________Date: _________________________